EVALUATION FOR QUALITY IMPROVEMENT OF THE FAMILY …189.28.128.100/dab/docs/publicacoes/geral/doc_tec_amq_ingles.pdf · IV. Guidelines for the Evaluation for Quality Improvement of

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Avaliação para Melhoria da Qualidade da Estratégia Saúde da Família

MINISTRY OF HEALTH OF BRAZIL

EVALUATION FOR QUALITY IMPROVEMENT OF THEFAMILY HEALTH STRATEGY

Technical Document

Brasília – DF2006

4

Documento TécnicoDocumento Técnico

Avaliação para Melhoria da Qualidade

da Estratégia Saúde da Família

5


MINISTRY OF HEALTHSecretariat of Health Care

Department of Primary Care

EVALUATION FOR QUALITY IMPROVEMENT OF THEFAMILY HEALTH STRATEGY

Technical Document

Series B. Basic Texts of Health

Brasília – DF2006

6


© 2005 Ministry of HealthAll rights reserved. This work may be totally or partially reproduced, if not for sale or any other commercial purpose. Anyuse of this work should be accompanied by an acknowledgment of Health Ministry as the source.The institutional compendium of the Health Ministry may be accessed through the Virtual Library at the Ministry of Healthwebsite: http://www.saude.gov.br/bvs

Series B. Basic Texts of Health

First published in 2005

Printed in Brazil

Catalogue Record

Brazil. Ministry of Health. Secretariat of Health Care. Department of Primary Care.Evaluation for Quality Improvement of the Family Health Strategy / Ministry of Health, Secretariat of Health Care.

Department of Primary Care. – Brasília : Ministry of Health, 2005.6v.- (series B. Basic Texts of Health)

Content: Technical Document – Notebook of self evaluation n.1: Health Municipal Management – Notebook of selfevaluation n.2 : Municipal Coordination of Family Health Strategy – Notebook of self evaluation n.3 : Family Health Unit – Notebookof self evaluation n.4 : Family Health Team : part 1 – Notebook of self evaluation n.5 : Family Health Team : part 2.

ISBN 85-334-1034-4 (complete work)ISBN 85-334-1035-2 (technical document)

1. Health care quality. 2. Evaluation of processes and results (health cares) 3. Family Health.I. Title. II. Series.

NLM W 84

Cataloguing in the source – MS Press – 2005/1197

Titles for indexation:In English : Evaluation for Quality Improvement of the Family Health Strategy : technical documentIn Spanish : Evaluación para mejora de la Calidad de la Estrategia Salud de la Familia : documento técnico

Formulation, distribution and information:Secretariat of Health CareDepartment of Primary CareCoordination of Monitoring and EvaluationEsplanada dos Ministérios, Bloco “G”, Edifício Sederters6 .° andar, sala 63570058-900 - Brasília – DFTelephones: (61) 3315-3434 / 3315-2391Fax: (61) 3326-4340E-mail: [email protected] page: www.saude.gov.br/amq

Supervison:Luis Fernando Rolim Sampaio

Geral Coordination:Eronildo Felisberto

Technical Coordination:Iracema de Almeida Benevides

Specialized Consultants in Evaluation and Quality:Ana Cláudia Figueiró – IMIPCarlos Eduardo Aguilera Campos – UFRJDaphne Rattner – Health of the Woman Technique Area/DAPE/SAS/MSFrancisco José Pacheco dos Santos – Bahia Secretariat ofHealth

International Quality Consultant:Luis F. Coronado, M.D., M.B.A.

Translation:Vanessa Marcondes

Technical Team:Andrea R. Leitão, Ávila T. Vidal, Eroneide V. da Silva, GiseleCazarin, Joseli M. Araújo, Letícia Milena F. Silva, Maria ÂngelaMaricondi, Marina Mendes

Colaboration:Panamerican Health Organization (Paho)Julio Suarez and Juan Seclen

United Nations Educational, Scientific and Cultural Organization(UNESCO)Heloíza Machado de Souza

Health Quality Institute / Portugal Ministry of Health (IQS)Luis Pisco

Infantile Maternal Institute Professor Fernando Figueira (Imip)Ana Cláudia Figueiró; Cinthia Kalyne de A. Alves, IsabellaSamico, Paulo Germano de Frias

Ministry of Health:Secretariat of Health CareDepartment of Primary CareDepartment of Strategic Programmatic Actions

Secretariat of Management of Work and Education in HealthDepartment of Management and Regulation of the Work in Health

Secretariat of Monitoring in HealthDepartment of Epidemiologist MonitoringDepartment of Health Situation Analysis

7


PRESENTATION

The guarantee of the quality of care is, nowadays, one of the chal-

lenges to the Unified Health System (SUS), considering the necessity of

its comprehension in light of the principles of comprehensiveness, univer-

sality, equity and social participation. Over the last 10 years the Primary

Care, in Brazil, has undergone an intense transformation from the defini-

tion of the Family Health Strategy in the reorganization of its practices

aiming a real standard change. This initiative intended also to expand the

access and coverage of the basic health services and to organize the

demand to other care groups, reaching social groups that have been ex-

cluded from comprehensive health care.

During this period the investment in network and human resources

expansion linked to the first level of care of the system, led to a continu-

ous growth of population access to health services and actions. However,

it is still imperative that the organizational development improve intensify-

ing the efforts destined to the improvement of the quality of health servic-

es and practices, to consolidate the strategy as the axis of the Primary

Care reorganization, with repercussion in the reordering in the health sys-

tem as a whole.

The proposal Evaluation for Quality Improvement of the Family Health

Strategy represents the institutional commitment to contribute to the con-

solidation of the Monitoring and Evaluation of Primary Care. According to

this, the usage of the quality evaluation becomes an important step to in

order to offer better health care to individuals, families and community.

Ministry of Health of Brazil

8


PRESENTATION

I. Introduction

II. Justification

III. Goals

IV. Guidelines for the Evaluation for Quality Improvement

of the Family Health Strategy

V. Family Health Strategy: Principles, Guidelines and actions

VI. Quality of Health Care according to the Family Health

Strategy perspective

VII. Evaluation methodologies of quality in health

VIII. Approach of the Evaluation for Quality Improvement of the

Family Health Strategy

IX. Quality standards: definitions and formulation methodology

X. Quality Levels in the proposal Evaluation for Quality

Improvement of the Family Health Strategy

XI. Predicted aspects for the implantation of the proposal

Evaluation for Quality Improvement of the Family Health Strategy

XII. Attributions of the governmental levels

XIII. International experiences of quality evaluation of Primary Care

BIBLIOGRAPHY

Appendix

Tool 1: Development of the Family Health Strategy

Tool 2: Technical coordination of the teams

Tool 3: Family Health Unit

Tool 4: Consolidation of the Family Health Care Model

Tool 5: Health Care

INDEX

7

9

11

13

14

15

22

23

25

31

36

40

42

44

47

49

56

66

74

82

94

9


The Evaluation for Quality Improvement of the Family Health Strate-

gy makes closer the connection between evaluation and the field of Health’s

Quality, enabling the agents who work in the municipalities the acquisition

of methods and tools to make this process by themselves.

To evaluate means to form an opinion, to judge, to decide about

something or someone after thinking carefully. Evaluation is frequently

associated with negative aspects such as punishment, ranking and elimi-

nation of the ones who haven’t reached a certain result. However, we

many times, find the concept or pre concept, that evaluation is a very

complex knowledge that can only be understood by specialists from the

services or the academy.

When it comes to quality, it is usual the idea that it is a very subjec-

tive field, so much so that there is no definite way to evaluate it. The idea

that it is not possible to offer good quality services within the Brazilian

Unified Health System (SUS) is also falsely spread.

In order to overcame these limited conceptions which are based on

historic and cultural precedents, the actual proposal sees the evaluation

as a permanent tool to decision making, and the quality as a fundamental

attribute to be reached by the SUS – and both of them should be appropri-

ated by any professional working within Family Health Strategy.

This document unites the methodological, conceptual and operation-

al references of an evaluation model to improve the quality of the Family

Health Strategy. Technicians; experts; health services managers, schools

and research professionals, as well as professionals from the three gov-

ernmental levels participated and contributed to its production.

I. Introduction

10



gy is a proposal that municipal secretaries of health shall take in a partic-

ipative and voluntary way, motivated by the will to offer a better quality in

Health Care.

• It proposes, as a nuclear methodology, a self evaluation oriented by

tools designated to specific agents and areas: municipal health man-

agement, coordination, health units and teams. This way, it places the

inner perspective, of self administration, led by the ones who develop

the strategy actions.

• It guides the formulation of a diagnosis about the organization and the

functioning of the services and its practices, starting from the Family

Health Strategy current struture (principles, lines of direction and act-

ing fields). It enables the identification of the development levels, the

critical aspects, as well as its potentials and consolidated matters. In

the same way, it leads the formulation of intervention plans to solve

the identified problems, in a strategic way.

• It can be used as a reference to the Family Health Strategy organiza-

tion in the municipalities, due to its strong guiding, pedagogic and in-

ductive aspect of good practices in health.

The content of this document does not intend to exhaust the evalua-

tion field and quality in health. It does not intended to be a singular path

that lead to an ideal situation about quality in health services. However, it

shows some ways and possibilities to be studied by different agents with-

in the different fields of strategic acting.

11


Offer the population accessible, resolutive and humanized health ac-

tions is a responsibility to be shared by the three administrative levels of

the Unified Health System (SUS). Investing in the quality improvement of

the services, considering all care levels, means to promote health and to

reduce risks and morbid-mortality¹, assuring better effectivness³ and ef-

fectivity.

The accelerated growth of the Family Health Strategy and the recent

investments in its expansion 10 years after its implementation calls for

reflection about its conception, execution and sustainability². It also de-

mands the creation of strategies destined to ensure the quality of its de-

velopment and the quality of the Health Care offered by the teams. In

order achieve this, it is essential to have the participation of all agents

involved in the organization, searching for new methodologies and tools to

implement the actions of monitoring, evaluation and improvement of the

available services4, including the organizational and operational aspects.

The use of evaluation processes, known as continuous critical-reflex-

ive action that can subsidize the decision making and influence the devel-

opment of the system concerning its functioning, working processes and

practices of management and service, helps managers and professionals

to get the necessary knowledge to identify health needs and assistance

demands, in order to reach the system resolubility and the users’ satisfac-

tion.

This way, the Evaluation for Quality Improvement of the Family Health

Strategy offers specific tools to this care model, enabling the agents who

work with the strategy within its different fields to evaluate it in a system-

ic and integrated way, in order to reach management, technical and scien-

tific improvement.

This proposal integrates a conjunct of actions, activities and experi-

ences developed within the policy for Monitoring and Evaluation of Prima-

ry Care, which is embedded in a wider process of institutionalization and

evaluation strengthening in the three governmental levels of the health

system. It brings evidence of the Ministry of Health’s commitment to in-

vesting, besides services expansion, in the continuous improvement of

actions, services and health practices and in the strengthening of the mon-

itoring and evaluation systems, which are essential tools in the SUS ad-

ministration.

II. Justification

12


General:

Promote the monitoring and the evaluation of the quality levels of the

Family Health Strategy.

Specific:

• To make available the tools that help in the diagnosis of the health situa-

tion and the intervention planning and to boost the continuous improve-

ment of quality in administration, services and practices in Family Health

Strategy;

• To verify the development levels reached by the municipalities consider-

ing all the components of a municipal administration, coordination and

team work;

• To identify critical areas and to support the health services managers in

the development of action plans aiming at the improvement of strategy

quality; concerning its organization and practices;

• To support, to follow-up and to evaluate the development of the improve-

ment initiatives of the strategy quality;

• To contribute to streghten the evaluating capacity within the quality field

in the municipal and state health secretaries.

III. Goals

13


GUIDELINES

� Self evaluating process;

� Free adhesion by municipal health secretaries, who should sensitize and

motivate coordinators and teams to participate;

� Lack of rewarding or punishment like financial sanctions or others related

to results;

� Use of a digital system to feed the data bases and make available several

kinds of reports;

� Integration to the developed activities within the State Plans for Monitor-

ing and Evaluation of Primary Care.

USERS OF THE PROPOSAL FOR THE EVALUATION FOR QUALITY

IMPROVEMENT

The development of a proposal for quality improvement stems from

the idea that the management, the structure and the current processes of

action implementation, services functioning and practices may be improved

in order to reach the desired quality5. However, users of this process may

come from different places and with different interests. This way there

should be a definition of the target public of the actual proposal.

Considering the goals of the proposal for quality evaluation as part

of a qualification initiative that allows pushing the development of the

Family Health Strategy, it is understood that its implementation is of

immediate interest to the municipal secretary of health, for this initiative

may provide information about various aspects concerning management

improvement and the services of Primary Care. Being a voluntary initia-

tive, its achievement depends on the interest of those involved with the

IV. Guidelines for the Evaluation

for Quality Improvement of the


14


local services in getting to know the difficulties and the accomplish-

ments experienced by the strategy, as well as to the politic decision and

the commitment of acting to solve the identified problems. So, it is in-

tended that the qualification for Family Health Strategy occurs through

formal and voluntary adhesion.

It is understood, as well, that health professionals must be involved

with the proposal development, for they are the responsible agents for the

consolidation of the health’s actions in its daily practices in the services.

Their attitudes within the working process are related to the available

knowledge, to their previous expectations and the context in which they

are inserted. Some of these aspects will be discussed in the quality evalu-

ation of the health teams and will allow the recognition of difficulties and

obstacles for the formulation and development of action plans, pointing to

the necessary investments, its nature and direction, aiming at reorganiza-

tion of the Primary Care, having the Family Health Strategy as an axis.

State and Federal levels of the coordination of the Family Health

Program also stand as users of this same process. To these the identifica-

tion of the main problems and the follow-up of the results in quality im-

provement got by the health teams, will allow a better comprehension

about the way the strategy is being developed within the country’s differ-

ent realities. This project will show the priority areas for investing as well

as the innovative and resolutive work experiences. It will also help to

identify new lines of action and different approaches to the problems and

needs of the health system users, as well as changes in the population’s

health situation.

BENEFICIARIES OF THE EVALUATION PROPOSAL FOR QUALITY

IMPROVEMENT

The main beneficiaries of this initiative are the users of the health

system themselves, identified as the focus of this proposal. The reach of

more advanced quality levels in the development of the Family Health

Strategy will represent an improvement of services, better resolubility and

humanized care, once these goals are pursued by health managers, pro-

fessionals and others agents involved in the continuous quality improve-

ment.

15


The Department of Primary Care (DAB) of the Ministry of Health

has established the basis for the implementation and functioning of the

Family Health Strategy since 1994. The organization of the Strategy in

the municipalities guides itself according to pre defined operational guide-

lines that will lead the way of functioning of the units and the teams

practice, including the regulation according intervention areas and stra-

tegic lines of action. It has to be highlighted that the municipalities have

searched, beyond the fulfillment of the operational guidelines, to explore

all strategy potentialities in order to reach equity and comprehensive-

ness within health assistance.

The effort for the reorganization of the Health Care System (SUS) in

Brazil presented new perspectives since the proposition of the Family Health

Strategy as the structuring axis of Primary Care. Pioneer experiences as

the Health Care Communitarian Agents Program (PACS) adopted by the

Ministry of Health in 1991, have served as inspiration for the Family Health

Program. Ever since, the model is being improved and extended to the

whole country as a strategy for this care level. In July 2005 there were

22.410 Family Health teams implemented in 4.791 Brazilian municipali-

ties, representing 86,2% municipality and offering coverage to 40,9% of

Brazilian population.

Nowadays Family Health Strategy has been implemented replacing

the traditional model for the Primary Care, making possible, in a defined

territory, complete and continuous care to individual and community health,

with actions of health promotion, protection and recovering6,7

. The health

actions are developed having the family as the center, understood in its

socio-cultural environment. In the Family Health Unity (USF) is settled the

multi professional team responsible for a pre determined population. This

organization favors the establishment of bonds of responsibility and trust

between professionals and families and enables an better comprehension

of the health/disease process and the necessary interventions considering

the identified problems and demands1,8

.

V. Family Health Strategy:

principles, guidelines and

actions

16


Having the SUS principles as conditions for its development, the Fam-

ily Health Strategy faces as a great challenge: reach universal coverage

and equity. The quality improvement and humanization are other goals to be

achieved. The development of its practices requires the integration of high-

ly complex technology in the knowledge area, with the establishment of

new abilities and attitude changes1. Besides that, and according to the prin-

ciples of Primary Care which point to the importance of coordination of the

actions considering professionals and care levels, a greater efficiency in the

use of the available resources is expected. In order to reach such goals

there were financial, educational and political incentives aiming at a redefi-

nition of the health actions objective, the reorganization of the local health

system and the reorientation of the work processes and health practices.

PRINCIPLES OF THE FAMILY HEALTH STRATEGY

Embodying and reassuring SUS basic principles – universality, com-

prehensiveness, equity and social participation – the work in the Family

Health Strategy is developed according the following leading principles9:

1. Substitutive perspective: the FH Strategy does not propose the cre-

ation of new structures, except in areas that lack any kind of service.

Replacing the traditional assistance practices, that focused on the dis-

eases, by a new work process committed with prevention, with quality

promotion in the population’s life and with assistance resolubility.

2. Comprehensiveness: the FHU is a synonym for Primary Care, becom-

ing the first contact between the population and the municipality health

system. It is expected that Family Health Team, with its knowledge and

practices, be able to identify and answer to the health needs, consider-

ing both individual and collective expression. Furthermore, the units must

be linked to the services network, in a way that both references and

counter references for any other level of the system be assured. Under-

standing comprehensiveness in its broader meaning, far beyond assis-

tance assurance in other care levels, both municipal coordination and

teams must search in other social segments the necessary complemen-

tariness to its actions and practices, aiming to accomplish the essential

requirements of health promotion and disease prevention.

17


3. Territorialization: the local work should be organized based on the pop-

ulation’s epidemiologic and social conditions. The team working ac-

cording to this logic deals with a definition of the coverage area and

enrolled population (which may vary between 2.400 to 4.000 people),

doing family registration, follow-up of health situation, harm exposure

and environmental conditions, besides developing programmatic ac-

tions. Within the teams’ acting territory, there is the definition of micro

areas. This allows a better follow-up of life and health conditions of

the families and enables the identification of inequalities and the offer-

ing of specialized care to the more vulnerable groups.

4. Multiprofessional Team: the Family Health teams are composed of at

least one doctor, one nurse, one or two nurse assistants and four or

five Health Care Communitarian Agents. Since December 2000, with

the creation of a financial incentive for the insertion of one Buccal

Health Team for each two Family Health teams, a progressive growth

of these professionals working within the strategy has been observed.

The ministerial norm n° 673/GM/MS, June 2003, predicts the incorpo-

ration of one Buccal Health team for each Family Health team accord-

ing the following conditions: one dentist and one dental clinic assistant

(DCA), and possibly, besides those two, a dental hygiene technician

(DHT). The actions for Buccal Health promotion are inserted in a broad

health concept which transcends the technical dimension of dental

assistance, incorporating itself into others public practices.

Other professionals – such as psychologists, nutritionists, social as-

sistants and physical therapists – may be incorporated composing support

teams, according to the local needs and possibilities. The FHU may act

with one or more teams, depending on the population concentration in the

territory under its responsibility. The approach to the problems and health

needs, as well as the organization and functioning strategy method, within

the comprehensiveness perspective, requires that the teams are able to

articulate technical requirements to a practice that considers individual,

familiar and collective contexts, and the relationship among professionals,

developing abilities and attitude changes.

18


5. Responsibility and bond: the teams take on as their own responsibility

to contribute to the improvement of families’ health and life quality,

considering the ones living within their comprised area or territory. In

order to do so they shall make efforts to offer humanized care, consid-

ering the subjective and social dimension of its practices, favoring the

formation of cooperative networks and promoting the people and so-

cial groups autonomy.

6. Community participation and social control: The health man-

agement must favor and strength the social participation in all fields of

the strategy. The team, for its turn, must promote the participation of

social organizations and its members in the planning, administration

and local health evaluation, and develop coupled projects for the im-

provement of the population’s life quality.

ACTING FIELDS OF THE FAMILY HEALTH STRATEGY

Health practices within Primary Care must comprehend all levels

concerning the health-disease process and intervention areas, such as:

Health Promotion was defined by WHO (1986) as “the process of

enabling people to increase control over, and to improve their health”. The

health pre-requisites go beyond the simple illness or lifestyle prevention,

including aspects1 such as “peace, protection, education, nourishment,

income, stable ecosystem, fairness and social equity”. The goal is to reach

the capacity of analyzing and acting over the social determinants of the

health-disease process, as well as acting on the problems that affect life

and life conditions10

.

Disease and health problems prevention works with the reduc-

tion of risk factors to individuals and social groups, counting on collective

health knowledge and methodologies in its various areas and programmat-

ic actions to do so. Primary prevention areas are emphasized through health

promotion (to prevent the disease in the population, intervening in the risk

factors), and specific protection (to prevent the disease in sub clinical

groups or risk groups). These actions include the ones predicted in epide-

miologic, sanitary and environmental monitoring area.

19


Treatment and Assistance (secondary prevention) are directed to

early disease recognition, the adoption of comprehensive individual, famil-

iar and community treatment measures according to the care level and

health technology development. In order to achieve this, health teams

must have access to work conditions that assure assistance quality to the

patients, the families and the communities, as well as a guarantee of

reference to the other levels of care of the system.

Health Rehabilitation (tertiary prevention) aims at the reestablish-

ment of the functioning capacity of people who had deteriorated due to

the illness process. According to the Family Health Strategy context, re-

habilitation actions require family closeness to the process and proper

housing conditions to achieve better results, as well as access to special-

ized rehabilitation services whenever it is necessary.

STRATEGIC LINES OF ACTION

It is expected that the health practices developed by the teams cov-

er all levels of the human life cycle (health of children, adolescents, youths,

adult men and women, elderly), the priority health problems, health needs,

transmissible and non transmissible chronic diseases (hypertension, diabe-

tes mellitus, tuberculosis, leprosy, STD/AIDS, malaria, dengue and alco-

holism) and programmatic actions (mental health, worker health, commu-

nity rehabilitation program).

It has been considered, in the formulation of the proposal and the

tools for the Evaluation for Quality Improvement, this extended view of

the organization, functioning and health practices within the strategy.

20


GUIDELINES FOR THE FAMILY HEALTH TEAMS’ (FHT) WORK

The FHT must know what happens within its coverage area and,

with this information (health diagnosis), work on action planning and fol-

low-up, monitoring of risk and disease situations and evaluation. It is ex-

pected that services and practices be organized in permanent interaction

with the community. Having that in mind, the main guidelines for this

work are:

1. Get to know families’ reality within the acting area, considering socio

economic, cultural, demographic and epidemiologic aspects, identify-

ing the most common health problems and the exposure risk for the

population.

2. Register the defined population in a cadastre.

3. Formulate a local health plan based on the health diagnosis of the

population, program activities and restructure the work process to-

gether with the community.

4. Perform health monitoring and act in the control of diseases such as

tuberculosis, leprosy, sexually transmissible diseases and AIDS, other

infectious-transmissible diseases in general, non transmissible chronic

diseases, besides the work and environment related illnesses.

5. Offer resolutive assistance, according to the demand and the main

health problems detected in the population, trying to articulate other

care levels in order to assure comprehensiveness in care.

6. Organize the health service emphasizing the family as the center of

the attention. In this way, implement health promotion actions and

strengthen the bonds with the community.

7. Develop educational projects within the population through communi-

ty groups, focusing on health improvement and life quality aspects.

8. Promote inter-institutional actions and actions with formal and infor-

mal community organizations to act together in the solution of health

problems, bringing up the themes of citizenship, right to health and its

legal basis.

21


9. Boost the participation of Health Municipal and Local Councils, strength-

ening the social control.

PROESF: A PROJECT FOR THE EXPANSION AND CONSOLIDATION

OF FAMILY HEALTH STRATEGY

The adhesion of the municipalities to the Family Health Strategy has

varied according their size, having the smaller cities been able to perform

its establishment faster and in an easier way than the larger ones. This is

related to multiple variables, like: socio-sanitary complexity, the existence

of already established Health Care models and aspects of urban organiza-

tion (buildings, condominiums, invaded areas), profile and formation of

professionals, among others.

In order to overcome the limitations related to the strategy expan-

sion in the big cities and urban centers, a project was developed which

main goals are to boost and extend the number of teams, to form profes-

sionals to work in the strategy and to strengthen the monitoring and eval-

uation processes in these locations.

The Project for the Expansion and Consolidation of Family Health –

PROESF is an initiative of the Ministry of Health, supported by the World

Bank – BIRD, aiming the strengthening of Primary Care in the country12

.

The Project is structured in three acting components:

I. Support the conversion and expansion of the Family Health Strategy –

directed to the municipalities with over 100.00 inhabitants.

II. Development of human resources within Family Health Strategy – di-

rected to the states and municipalities, regardless of its size.

III. Monitoring and evaluation – directed to states and municipalities, re-

gardless of its size.


gy integrates component III of the PROESF, together with the Base Line

Studies and the State Plans of Monitoring and Evaluation of Primary Care,

among other actions.

22


Conceptually, quality will always be a social formulation, constituted

by references of the involved parties – who attribute meanings to their

experiences, giving privileges or excluding certain aspects according a

hierarchy of preferences.

Thus, it will always be a great challenge to search for a quality con-

cept approach concerning the Family Health Strategy, considering the plu-

rality of its dimensions (politic, economic, social, technologic) and the

agents involved in its development (individuals, families, communities and

professionals) 13,14

.

Concerning this proposal, quality in health will be defined as the ob-

tainment of established quality standards according the norms and proto-

cols which organize actions and practices, as well as the actual technical

and scientific knowledge, respecting culturally accepted values15,16

. The

assistance to the health needs and the users and their families’ expecta-

tions, as well as the answer to the technically defined necessities will also

be considered.

VI. Quality of health care

according to the Family Health

Strategy perspective

23


There are different alternatives to evaluate health quality consider-

ing actions services and practices. They can vary according to the per-

spective, purposes, methodology or mechanisms.

The evaluation perspective may be of external17

or internal nature,

depending on the agent that requires, conducts or validates the evalua-

tion. Among the ones of external nature there are Accreditation, Certifica-

tion and Licensing, when external agents formulate the final result, this

being a score, a certificate or a license. The Evaluation for Quality Im-

provement is based on the internal evaluation perspective, considered more

appropriate for the Family Health Strategy because it is conducted, in all

levels, by its own involved parties.

EXTERNAL EVALUATION

ACCREDITATION: It is a process of evaluation and measure of the

formal quality of the work developed by a health organization, which uses

standards defined by an Accreditation Commission (generally a non-gov-

ernmental organization) that is not related to the institution to be accredit-

ed. The commission recognizes as excellent a service or health organiza-

tion that, having developed a process of quality improvement, surpasses

the pre-established measurement standards. The accreditation process is

voluntary (required by the organization to be accredited), periodic and

systematic, and is applied in a national, regional or local context.

CERTIFICATION: Through this process an organizational station (gov-

ernmental or not), evaluates and recognizes a person18

or organization

that accomplishes the requirements or pre-established criteria (example:

ISO-9000).

LICENSING: Through this process a governmental authority gives

permission to an individual health professional or a health organization to

perform health services. It is sustained by the compliance of certain mini-

mum requirements of services offering. The license has a validation period

that requires its continuous renewal, according the International Organiza-

tion for Standardization (ISO)19

.

VII. Evaluation methodologies

for health quality

24


EVALUATION FOR QUALITY IMPROVEMENT

� Evaluation perspective: internal

� Participative process that includes health managers,

professionals and other parties involved with intervention

� Articulated initiative of the three administration levels of the

Family Health Strategy (municipal, state and federal)

� Promotion of the evaluative culture and of the management

of the quality improvement in Primary Care

� Process inserted in a program of continuous quality

improvement

INTERNAL EVALUATION:

CONTINUOUS QUALITY IMPROVEMENT (CQI): processes ori-

ented to quality promotion in Health Care in a systematic and continuous

way, designed to reach the quality levels oriented by the care model ac-

cording the social demands and the scientific and technological advance-

ments in health.

The Evaluation for Quality Improvement in the Family Health Strate-

gy uses the evaluation internal perspective, articulating elements of the

normative evaluation and the continuous quality improvement (CQI), pre-

senting itself as a methodology of services internal administration. Start-

ing from the pre-established criteria and standards, it aims to boost pro-

cesses of quality improvement, offering the health manager a work tool

that makes the strategy proposals easier to reach.

25



gy adopts, as a conceptual reference in the evaluation field, the model

proposed by Donabedian based in the systemic theory which considers

the elements of structure, process and result21

, having as an analysis fo-

cus the health services and assistance practices.

Figure 1: Evaluation elements of the Family Health teams

Considering this, the proposal was defined:

1. The self evaluation tools emphasize the elements of the process,

especially the work processes, because these offer wider and more

accessible intervention possibilities once the problems are identified.

Even though the emphasis is smaller, the aspects of structure and

result are also taken as parameters to quality evaluation, from a dy-

namic view of inter related quality levels25

.

VIII. Approach of the

Evaluation for Quality

Improvement of the Family

Health Strategy

Supplies

Teams

Materials

Human Resources

Physical Environment

Normative Organization

ASPECTOS

• Organizational

• Technical-scientific

• Interpersonal

• Access

• Suitability

• Effectiveness

Changes in

the health

of the

population

STRUCTURE RESULTS: DIRECT AND FINALPROCESS

26


2. Two nuclear components or analysis units for evaluation were defined:

Management and Teams. Afterwards, the activities developed in each

one of them were listed, determining the thematic sub dimensions of

the elements. For each sub dimension quality standards were proposed

and validated. Even though two components are organized in an equiv-

alent manner, as parallel elements, there should not be neglected the

fact that the management component determines the conditions and

opportunities for the team component to happen, basing itself in the

understanding that adhesion, coordination and creation of favorable

conditions for the implantation and implementation of strategies de-

pend mainly on the politic will of the municipal secretaries of health. It

must be highlighted that the structure elements, although they may

and should be evaluated within teams’ work, are the managers’ re-

sponsibility.

In many evaluation standards, proposed to both components, a

great deal of importance is given to the development of new abilities

and attitudes by the managers, coordinators and professionals, as well

as initiatives concerning changes in work processes and team prac-

tices, aiming at the effective development of inter-institutional ac-

tions and health promotion.

Figure 2: Components or Analysis Units for the Evaluation for Quality

Improvement of the Family Health Strategy

Component 2:

Family Health

Teams

EVALUATION FOR QUALITY

IMPROVEMENT OF THE FAMILY

HEALTH STRATEGY

Component 1:

Health management

and coordination of

the strategy

27


The aspects of the municipal management of the Family Health

Strategy to be evaluated include the priority given by the health manager

to the strategy, its capacity of conducting inter-institutional actions, be-

sides the organization, the planning, the work administration and manage-

ment of the actions and services, monitoring and evaluation, as well as

social participation in the formulation, execution and control of the ac-

tions. These elements must show the strategy principles taken as refer-

ences to its implantation and development in the municipality.

The aspects that refer to the structure for the proper functioning of

services and practices of the Family Health Teams are:

o Infrastructure: professionals and health agents of the FHU, physical

environment (units, offices availability, appropriate places to attend

the patients, work meetings, educational activities) and equipment.

Although the infrastructure provisions are verified in the FHU, this is

understood as a responsibility of the municipal health manager.

o Normative aspects: the existence and the use of guidelines, manuals,

protocols, among other documents.

The evaluation of the Family Health Teams will focus on the as-

pects of process and result related to the acting fields, established goals

and guidelines.

Comprehensive Care

Goals and

guidelines of the

FH Strategy

• Health promotion

• Health problems and disease prevention

• Early diagnosis and treatment

• Rehabilitation

• Diagnosis

• Action planning

• Usage of norms and protocols

• Evaluation of the coverage, performance and results

• Promotion of inter-institutional actions

• Attention focus on the family and community

28


The Processes refer to predicted actions for the FHS and FHU func-

tioning, as well as the intervention and interaction among users and pro-

fessionals. The processes, will be evaluated according to the organization-

al, technical and scientific aspects, besides the interpersonal relationship22

.

ORGANIZATIONAL ASPECTS

It is considered the team actuation in the organization of services

and practices, internally and in its interaction with other social partici-

pants, institutions and local organizations, observing:

o Planning: appointment making, assistance to spontaneous demand,

access, making a cadastre of the population, availability of services,

programmatic actions, coordination of other system levels, mecha-

nisms of monitoring and evaluation, ombudsman, information systems

of good quality.

o Scope: mobilization of resources and efforts of the various partici-

pants and social segments for the obtainment of adequate health con-

ditions.

o Community participation: aspects such as planning, implantation, mon-

itoring and evaluation of the actions in health are fundamental axes of

united actuation between the community and the health services.

TECHNICAL SCIENTIFIC ASPECTS

o Technical scientific competence: includes the activities designed to

enhance health awareness, abilities and practices. The activities of

the continuing education must remain in line with the goals of the

strategy and stay tuned with its operational principles. In these as-

pects, quality refers to comprehensive health practices including health

promotion, risk and diseases prevention, early diagnosis, initial treat-

ment, guiding and temporal rehabilitation.

o Protocols: development and use of manuals and guidelines for assis-

tance, prevention and health promotion according the advances in sci-

ence and health technology and the SUS principles.

29


INTERPERSONAL RELATIONSHIP

o Commitment: is directly related to adequate and humanized care that

the service offers its users, besides the operational dimension, com-

plaint hearing and health needs, searching for resolute attention through

the articulation of the services network23

. This aspect is fundamental

because it influences aspects such as the trust levels between provid-

er and user, adherence to indications, assistance continuity, individual

respect and users’ satisfaction, among others.

o Interpersonal communication: health results depend, mostly, on the

information level and communication that may exist during the execu-

tion of practices. Relevant aspects include information about the health-

disease process, health risks, treatment, prognostic, prevention, col-

lateral effects of medication, risk minimization, health care.

The results consider the effects of the processes in the concretiza-

tion of the actions and practices performed by the teams according the

principles and goals pre-established. We can observe two kinds of results:

direct and final.

o The direct results relate to the effects of the actions and practices

developed in the HFU concerning access (coverage enlargement, if

the population got the necessary care and if it got the care when it

was required), suitability (adequate offer of services in quantity and

quality, according the available knowledge and technology, and the

capacity to anticipate problems and risks) and effectiveness (suffi-

cient effort put forth to satisfy needs and demands of the population’s

health, that is, positive impact on the epidemiologic indicators when it

comes to internment caused by avoidable disease, morbidity and mor-

tality).

o The health final results depend on many factors non-related to the

rendering of care in the first level of the health system, but also to the

other levels of care of the system, and especially of the participation

of the other sectors of the society and the social conditions.

Table 1 shows the general structure of the Units of Analysis (Compo-

nents) defined by the Evaluation of Quality Improvement and the respec-

tive sub dimensions or thematic areas.

30


Table 1: Components or Units of Analysis, Dimensions and Sub dimen-

sions proposed by the Evaluation for Quality Improvement of the Family

Health Strategy.

Components

or Units of

Analysis

Dimension Subdimensions

Implantation/ Implementation of FH in the municipality

Integration of the Service Network

Work Management

Streghthening of the FH Coordination

Planning and Integration

Assistance of the Family Health Team

Permanent Education

Evaluation Management

Normative Actions

FHU Infrastructure and Equipments

Supplies, Immune-biologic and Medicines

Organization of the Work in Family Health Strategy

Commitment, Humanization and Responsibility

Health Promotion

Community Participation and Social Control

Health Surveillance I: General Actions

Children’s Health

Adolescent’s Health

Adult women and men’s Health

Elderly’s health

Health Surveillance II: Transmissible Diseases

Health Surveillance III: Regional Health Problems

Loco-regional standards

Development of the FH

Strategy

Technical Coordination

of Teams

FH Unit

Consolidation of the

Family Health Care

model

Health Care

Management

Teams

31


Definition and standards characteristics:

A standard is defined as a level of quality reference that must be

reached by the organization aiming to demonstrate a certain degree of

quality and excellence. The standard is the declaration of expected quali-

ty24

. Its direction is affirmative or positive and expresses expectations and

desires to be achieved. In the formulation of health standards it must be

considered that they are appropriate at the moment, acceptable to the

users and applicable.

Quality standards are used, frequently, in both mechanisms of quali-

ty evaluation, internal or external. Facing the growing interest in quality

improvement programs, mainly by accreditation in hospitals, The Interna-

tional Society for Quality in Health Care (ISQua) defined principles to the

formulation of standards based in key concepts, independently of their

content and application area25

. In order for the standards to become legit-

imate, get professional adhesion and have applicability to a daily use in-

side the health system/service, some basic characteristics are required:

1. Scope: It refers to a complete view of the system, having as reference

the traditional focus of structure, process and result. In this proposal

the concept has been enlarged to the utilization in the entire national

territory, or pre determined groups, considering the different levels of

care of the health system and the actions of promotion and preven-

tion26,27

.

2. Sensitivity to evidence changes: The standards shall have the capacity

to evidence the process of quality improvement and evolution, the ad-

vances and, also, the retrocession in the quality levels reached when it

comes to the aspects of management, organization and rendering of

services.

3. Simplicity in the application: they must be comprehensible and easy to

apply during the evaluation moments.

IX. Quality standards:

definitions and formulation

methodology

32


Table 2: PRINCIPLES TO STANDARD FORMULATION

1. Identification and definition of concepts. The standard content must be wide and clearly

structured, reflecting the type it belongs to, its scope and the activities or groups it is

designed for.

2. Identification and definition of the standard type. The standards are classified in three

types – structure, process and results. As no type is superior to the other, all of them

may be appropriated in any moment of the development of the quality program in the

country.

• Structure standards: are used to analyze the structure capacity of an organization to

provide health care, in the physical aspect (material, equipment, buildings and personnel)

or in the organizational aspect (norms, routines, protocols, planning).

• Process standards: describe how an activity happens (actions, practices, health proce-

dures).

• Result standards: measure the degree or level of quality reached and its effects accord-

ing the requirements previously established.

3. Precise definition of the standard extent. The standards must be oriented in order to

facilitate the quality improvement within the work process of a health organization, be-

ing an establishment, a service network or an entire health system. It must be defined if

they cover the totality of actions, just a part, or if they focus on specific activities or

groups of patients.

4. Clear definition of the process of standard formulation. In standard formulation we can

employ a six-part process:

a) participation of the users in its formulation;

b) consultation with the key sectors, for which it is designed, assuring that these have the

opportunity to contribute in its formulation;

c) developed according the national/regional laws and regulations;

d) proper investigation that assures that the standards are based in legitimate, practical

and updated information;

e) guarantee that the standard has been validated by Pilot studies before its definitive

implantation;

f) definition of the evaluation process and periodic revision of the standards.

5. The standards allow performance evaluation. The measure of the performance against

the standards use may aid in the creation of sophisticated numeric scales and mathe-

matic formulas, as well as simple verbal descriptions. And it can be verified by valua-

tors externals to the organization or by self-evaluation.

6. Continuous standard revision. The standards have a lasting period depending on the

quality level wanted and achieved by the organization. This temporality characteristic is

fundamental in the perspective of pushing the actions continuity in aid of quality.

33


Reference axes to standard formulation

The reference axes were defined from aspects considered funda-

mental and guiding to the formulation of quality standards: principles, guide-

lines, norms and consensus. The diverse responsibilities, acting fields and

parties involved in each of the components of the Family Health Strategy

require equal diversity in the reference axes.

Reference axes to the management component: The munici-

pal health managers have a conjunct of responsibilities and duties such as:

planning, organization, action management, monitoring and evaluation. In

keeping with the goals of reorganization of the local health system having

as a structural axis the Family Health Strategy, the manager and the local

coordinator must promote and/ or support political and organizational ca-

pacity for the effective and efficient conduction of the health system in a

way that responds to the populations’ expectations. In what concerns

Family Health Strategy these responsibilities must be achieved according

its guiding principles.

Reference axes to the Teams component: Being a strategy con-

cerned with health promotion and risk management, diseases and health

problems prevention, securing the access, assistance quality and its resol-

ubility, it is necessary to define the reference axes that reflect that goal.

They must, also, be tuned with the norms of the country, in order to push

program accomplishment, which describes the responsibilities of the pro-

fessionals and the Family Health team.

34


Formulation and validation of the quality standards

The standards defined by this proposal were formulated and validat-

ed with the contribution of key parties, in a wide participative and shared

process, according the achievement of the following steps:

• Formulation of a preliminary proposal for the standards: from the pro-

posal methodological design, technicians and consultants of the Coor-

dination of Monitoring and Evaluation of the Primary Care Department

(CAA/DAB) defined a preliminary relation of quality standards.

• Internal Validation (validation of the standards with experts): it was

held through the presentation and discussion of the preliminary stan-

dards with a wider work group composed by technicians from the

Ministry of Health (representing the areas within the proposal), exter-

nal consultants of the MH and representatives from the states and

municipalities, as well as potential users. This step enabled a first

adjustment of the proposed standards considering their goals (the stan-

dards are suitable to evaluate what is intended – validity), object (the

aspects to be evaluated are the ones that most need evaluation), reach

(users and beneficiaries) e evaluation purposes (suitable to the estab-

lishment of the development level and quality improvement in the Family

Health Strategy)

• Formulation of the tools to quality evaluation: after the realization of

many workshops to come to a consensus on the selection of standards

(emphasizing the following characteristics: universality, sensitivity,

applicability), tools were developed to evaluate the quality of the strat-

egy management and the actions of the Family Health teams.

35


Validation of the measure tools:

The tools and their standards were submitted to analysis according

the validity (to measure what is intended), reliability (to be reputable) and

applicability (to be of easily understood and used), with the following meth-

odology:

• Pre validation with potential users: a detailed discussion of the stan-

dards was conducted, initially formulated in pre test, carried out in

two municipalities, including health managers, coordinators and pro-

fessionals of four FH teams. The main goal was to make clear the

applicability degree and the pertinence of the selected standards and

the tools designed in municipalities of different regions, in diverse con-

ditions of economic development, population size, management condi-

tion and population coverage of the strategy.

• Validation: after the analysis of the level described above, standards

and tools to quanti-qualitative pilot test carried out in 24 Brazilian mu-

nicipalities were re-formulated, with the participation of over 500 teams

distributed throughout the 5 regions. The debates and opinions of these

collaborators about the self evaluation tools were decisive in the result

obtained and the formulation of the definitive material.

• Final adjustments: after the pilot test there was a re-organization of

the tools and standards by technician and consultants of the MH di-

rectly responsible for the proposal and representatives of the various

technical areas involved.

36


Although there are many considerations in literature about the non

linearity quality of the structure, process and result elements, for the present

proposal the quality improvement is approached in a continuous way, be-

ginning with the structure and infrastructure conditions, going through the

services and practices organization and forward to the more complex ac-

tions, in the work processes and in the impact over the health conditions

of the assisted population. This option reflects the educational, pedagogic

directionality that is intended with the proposal.

In the self evaluation tools, the concept of quality levels is associated

to each of the standards, which are presented below:

Level E Standards

Elementary Quality (addresses fundamental elements of structure and the

most basic actions of the FH strategy);

Level D Standards

Development Quality (addresses initial organizational elements and the

improvement of some work processes);

Level C Standards

Consolidated Quality (addresses consolidated organizational processes and

initial considerations of coverage and actions results);

Level B Standards

Better Quality (addresses actions of greatest complexity in care and more

lasting and sustained results);

Level A Standards

Advanced Quality (is the goal to be reached, concerning structure, pro-

cesses and, primarily, in results).

X. Quality Levels in the

proposal Evaluation for Quality


Health Strategy

37


It is expected that these levels do not represent stagnant situations

of unaltered quality but that they reflect moments of the process of the

group involved in the strategy and the successes in the reach of a pool of

standards. In this sense, the analysis result is not a level classification of a

municipality in relation to another, but a possibility of evaluating the qual-

ity of the strategy in all aspects (management and team) and/or in pre

defined aspects (child health, women health, for instance). The standards

will be continuous and opportunely revised so that they are updated and

compatible with the expected quality improvement.

The quality evaluation interacts with the natural process of quality

evolution in services, making it possible to objectively view the advances

and gains in the process as a whole. There is, this way, a process of

quality gradients, where each one corresponds to “moments” of the pro-

cess of quality maturation (Graph 3).

The present proposal, as a technical and methodological decision,

38


formulated standards exclusively of the categorical type, like “yes and

no”, disposed in incremental and ascendant levels. This decision was based

in the need to establish well defined quality principles and criteria consid-

ering the great territorial extension and the diversity of initiatives in FH

strategy in Brazilian municipalities. It also considered the various aspects

and progressive degrees of quality of the approached matters in each

standard, as well as the incremental classification of them, enabled by the

levels of quality development, from elementary to advanced.

The standards disposition in the tools was conceived according a

temporal and incremental evolution, searching to absorb, as an evaluation

tool, situations related to the implanting process of the Family Health strat-

egy, levels E, D, C, evolving to situations related to the guarantee of qual-

ity of the actions developed, levels B and A.

The transient quality of the standards emphasizes the concept of

“standard life cycle”, that is, the standards will be of use during the period

in which quality improvement allows for their attainment. Once that mo-

ment is passed, the standards may lose relevance and must be replaced

by others that reflect new quality levels.

Measures and Classification

There are many possibilities in the creation of grading scales in qual-

ity28

, of different levels of complexity, some of which use descriptive and

simple analyses, based on the fulfillment, or lack answer of the quality

standards. Other models are based on complex statistic proofs of analyt-

ical nature (multivariate models)29

that make a selection of the most rele-

vant standards (through the technique of analysis of the main compo-

nents) or other models that propose balance (grades) having as reference

statistic procedures as the factorial analysis30

.

There are, still, methods based in numeric scales applied, for exam-

ple, in evaluation of health interventions31

, where the definition of mea-

sures and the establishment of grades for the measurement of quality

levels are accomplished through consensus techniques with people of not-

ed knowledge on the issue.

39


To this proposal, considering the great diversity of the Brazilian health

system, as well as the fact that this is a pioneer experience, qualification

scales that are simple, consensual, of easy applicability and acceptability,

with an understanding at a local level were developed in order to assure

adherence, internalization and continuity of the model by the various par-

ties involved. The attribution to each standard of its corresponding quality

level consisted of the methodological option chosen by the technical team.

This way, each standard represents a structure, process or result ele-

ment, inside a certain dimension, allowing a wide and process based diag-

nosis of the strategy situation in the municipality, in its different aspects:

management, coordination and teams.

The levels initially achieved by the municipalities must continually

evolve, as a result of the improvement actions of management, organiza-

tion and rendering of services. In order to do so, the health managers

must institute a strategy of continuous sequential and horizontal commu-

nication with the coordination and professionals in order to strengthen the

successful projects and overcame the operational weaknesses identified,

assuring proper working conditions32

. The coordinators and the teams must

also identify the problems that should be solved first, their causes and

alternative solutions that can be applied in an adequate and effective way.

Considering the constant evolution of the functioning of the Family

Health Strategy in the country, as well as the transient quality of the

standards, the interval between the self-evaluations must be of six months

to one year, enabling the evidencing of the changes promoted by the local

initiatives to quality improvement.

40


The Evaluation for Quality Improvement of the Family Health strate-

gy intends to evince situations susceptible of being modified, stimulating

organizational changes directed to achievement of a better quality level of

the Health System.

Recognizing the different contexts of the proposal implantation, the

specifics of each reality and the importance of including, in its execution,

the various groups involved, the following aspects are predicted:

- Knowledge of the proposal by the municipalities.

- Health Managers interested in instituting a process of quality improve-

ment will adhere through inscription on the site of the project

(www.saude.gov.br/amq), and they will search to sensitize and moti-

vate the teams to participate.

- The self evaluation tools will be distributed among the professionals.

The answers can be registered in a computing system, accessible through

the internet. The data base will enable the consolidation of an evalua-

tion record and, latter on, feed reports for evaluation and analysis.

- Considering the result of the self evaluation held, the municipalities will

be able to identify problematic situations that may be revised/ modified

using proper work methods and making the feasible interventions con-

sidering the local conditions.

- As a work process to interfere on the identified situations, the next step

will be the formulation of action plans for the improvement of situa-

tions. In order to do so the proposal counts on tools that help in the

formulation and implementation of plans, which, for quality improve-

ment programs, follow the following steps:

XI. Predicted aspects for the

implantation of the proposal

Evaluation for Quality


Health Strategy

41


Some of the aspects considered problematic may be complex and

difficult to solve in the local and present conditions. Many, however, may

be approached according the local conditions and possibilities. It is sug-

gested to initiate the action plans in these cases (the easy cases and

situations), as they make it possible for the team to see the result of their

efforts before being able to work over more complex processes.

- Initially, the evaluations should be performed each semester. In this

occasion the procedure will be the same of the first evaluation, making

possible the continuance or the change in the quality levels (response to

the standards) in relation to the previous classification.

- Development of supporting and assistance nets through university nu-

cleus focusing on the quality area is predicted. These will be stimulated

to give support and assistance to the municipalities that are engaged in

the process of quality improvement of the Family Health Strategy.

- The possibility of external validation through later evaluation performed

by team, assigned specially to this finality, is being studied. This step

will enable the corroboration of the achieved advances in quality within

the evaluated work processes. These evaluations will be performed

with the agreement of the parties involved in the implantation of the

proposal.

Processes analysis; definition of which changes may improve them

and the formulation of an action plan contemplating the objective

of this change (that will always be related to the goals of the FH

strategy and focusing on the users), the activities to be achieved

(or the processes to be improved), the responsible agents and the

deadline for its execution.

Plan development in a small scale, as a pilot.

Checking whether the changes predicted by the plan are taking place.

If the evaluation is positive, it is implanted in a large scale; if not,

the plan is revised and the cycle starts all over again.

Planning

Execution

Evaluation

Implantation

42


The implantation and the positive development of the proposal re-

quire the definition of the assignments and implantation goals to the differ-

ent levels of the government and involved parties, as well as commitment

to its achievement. The participation and co-responsibility of the manage-

ments in the federal, state and municipal scope are extremely necessary

to the initiative achievement.

The priority of the proposal is to contribute to strength the process of

institutionalization of monitoring and evaluation of Primary Care in the

three government levels. In this way, the implantation process as an op-

portunity to reach that goal.

It is defined the following attributions and goals implantation to the

different management levels:

1. Federal Level: The Ministry of Health, through the Coordination of Mon-

itoring and Evaluation of the Primary Care Department, will be respon-

sible to accomplish the activities of planning, monitoring, evaluation,

promotion and negotiation of the proposal together with the involved

organizations.

Attributions:

• Formulation of the Proposal of Evaluation for Quality Improvement, in-

cluding its standards and tools enabling a participative evaluation to be

made with an accord.

• Proposition of steps and deadlines for the implantation.

• Presentation and negotiation of the proposal with public and social or-

ganizations.

• Presentation of the proposal through seminaries, national workshops

and events.

• Financial cooperation for the states to the implantation of the proposal:

through the State Plans of Monitoring and Evaluation of Primary Care.

• Technical support to the states for the presentation and implantation of

the proposal in the municipalities.

• Monitoring and evaluation of the implantation process and proposal de-

velopment in the national scope.

XII. Attributions of the

governamental levels

43


2. State Level: It is proposed to the states to support the process in all its

steps, working together with the municipalities for its implantation and

implementation.

Attributions:

• Integration of the Proposal to the State Plans of Monitoring and Evalua-

tion of the Primary Care.

• Presentation of the proposal to the municipalities through seminars, re-

gional and municipal workshops.

• Planning the steps of implantation of the proposal in the state.

• Follow-up and technical support to the municipalities in the process of

proposal implantation and development.

• Monitoring and Evaluation of the process of implantation and develop-

ment of the proposal in the state level.

3. Municipal Level: The municipal secretariats of health are the focus of

the proposal development, along with the accomplishment of the ac-

tions for quality improvement.

Attributions:

• Organization and coordination together with the state technical team

for the implantation of the proposal in the municipality,

• Planning implantation and development of the proposal.

• Presentation of the proposal to the parties and social segments involved:

managers and professionals of the Municipal Secretariat of Health, pro-

fessionals of the Family Health teams, Health Council (Municipal, Dis-

trict, Local Council).

• Involvement of the social parties responsible for the implantation and

achievement of the actions for quality improvement.

• Viability of the necessary conditions for the execution of the programmed

actions for the self evaluation of the quality and for the development of

the actions for quality improvement.

• Monitoring and Evaluation of the process of implantation and its devel-

opment within the municipality.

44


The field of quality evaluation of the primary health care, until the

present moment, may still be considered incipient in the country. It is

interesting to notice that the studies about health quality in the European

continent had their origins in the area of Primary Care, with special impor-

tance of the United Kingdom34

, which developed pioneer initiatives in this

area. These have always been conjugated actions among the medical cor-

poration, the government and the academy in order to reach quality im-

provement.

The actions in the area of Quality of the Primary Health Care have

been expanded, mainly, among the European countries and Australia. Since

the formation of the Leeuwenhorst Group, during the II Conference in the

Teaching of General Practice, in Noordwijkerhout, Holland, in the year of

1974, the matter of Primary Care structure has been the object of atten-

tion of professional corporations, educational institutions and health assis-

tance. The group mentioned above, composed by 15 members of 11 Euro-

pean countries produced three important documents or Declarations.

The first one, in 1975, revised in 1981, defined the work of the

physician and described the objectives of the training and formation of

specialists. In 1977, a Second Declaration had contributions for the gen-

eral practice in graduation. The third Declaration approached the team

of continuing education. The process of European unification reinforced

the need of gauging the graduation and post graduation formation. The

discussions about the matter of quality of the Primary Care gained more

importance with the debates promoted in the European Section of the

World Organization of National Colleges, Academies and Academic As-

sociations of General Practitioners/Family Physicians – WONCA and cul-

minated with the creation of the EQuiP34

, (European Working Party on

Quality in Family Practice), approved in the WONCA European Council,

in 1990, in Barcelona. It has begun its activities in 1991, in Utrech,

Holland, and nowadays has 23 delegates in European countries, nomi-

nated by the National associations.

XIII. International experiences

of quality evaluation of

Primary Care

45


A subsection of the WONCA – Europe aims to achieve its goals by

promoting collaboration between organizations, associations and colleges

of general practitioners/family doctors in Europe on the topic of Quality

Development. Besides the European group there is also a World Group in

WONCA, for quality, composed by Australia, Mexico, South Africa, Nor-

way, Finland, USA and Philippines.

According the EQuiP their work on Quality Development must:

• be an internal and continuous process and an integral part of learning

and improvement of the professionals;

• cover all aspects of patient care; taking into account structure, process

and outcome;

• be a routine part of daily practice, and therefore, must be valid but also

simple in their implementation,

• be patient-oriented, including the evaluation of accessibility and satis-

faction;

• enhances appropriate use of services in health care, and validate strat-

egies of the Primary Care, such as: continuity and comprehensiveness;

• make decisions explicit;

• be used as a professional and educational activity and not in a punitive

manner or for control purposes

Among the contributions of EQuiP it is the expertise and experience

exchange on Quality Development. In this way, we can mention many

initiatives of tools for quality evaluation developed in the last ten years in

many countries or in countries partnerships, such as: Moniquor (Portugal),

Primary Care Group Standards – United Kingdom; EPA – Germany, Swit-

zerland, Holland; VIC – Holland; EUROPEP – EU; Standards for General

Practice – Australia. Many others initiatives have been implemented in

the development of protocols, manuals, analysis of clinic and organiza-

tional evidence35,36

.

We can mention two tools that propose standards for the continuous

improvement of primary health care. The first one, named Standards for

General Practice37

, produced by The Royal Australian College of General

Practitioners, has as goals: to search for better levels of practice quality,

achievable in a gradual way; to purvey a public and recognized tool of

quality measure of general practice; to be voluntary; to be available and to

offer tangible benefits to the professionals; to be established in a deter-

mined period of time; to be an educational and gradual process, no punitive;

to be of an equitable basis for the entire country; to work as an evaluation

among pairs; to be of control of the own professionals; to have non lucrative

purposes, to be known by the governments and communities. With two

already developed versions, respectively in 1991 and 19996, this last one

composed by 212 standards of the categorical type for self-evaluation.

46


The MoniQuOr.CS38

- Assessing and Monitoring Organizational Quali-

ty in the Health Centers – developed by the National Institute for Quality

in Health of the Portuguese Health Service is the second tool to be men-

tioned. It fits in a global strategy of Continuous Improvement of the Health

Care Quality and it is mainly concerned with the Organization of the Ser-

vices and with the continuous and systematic revision of the processes

that lead to the delivery of effective and efficient health care services.

Among its goals are: monitoring and evaluation of the performance levels;

responsibility; the validation of documents and procedures; continuous and

systematic revisions of the processes of continuous improvement; formu-

lation of programs for continuous improvement; the improvement of inter-

nal communications; the organization of patient centered services; the

formulation of an action plan; the external recognition; the strategic plan-

ning of quality. Created in 1997, it is now undergoing a process of revi-

sion.

This tool proposes as methodology the self-evaluation, the evalua-

tion among pairs and the external evaluation. It is composed by 163 qual-

ity criteria, 73 of the categorical type (“yes” or “no”) and 90 with answers

according the scale: not implemented/in progress/ almost implemented/

totally implemented. The criteria should receive values according to the

following definition: not implemented (0), in progress (0,33), almost imple-

mented (0,67) and totally implemented (1). Both tools mentioned above

are mainly concerned about the structure and process evaluation, search

to promote the participation of its own professionals in the dynamic of

assessment and development of diagnostic process, situation analysis and

election of priority areas.

In Brazil, there are some initiatives of some State Secretariats of

Health aiming to search standards to quality monitoring in order to create

a politic of financial incentives, support and strengthening of the Family

Health Strategy in the municipalities. Recently, the Ministry of Health, in

technical cooperation with the Pan American Health Organization initiated

the formulation of this proposal aiming to fulfill the need of tools and

projects in this field. This initiative corroborates the importance for the

public health management to view the quality matter as one of its priori-

ties for the development of the Primary Care in the country, together with

the efforts to the consolidation and expansion of the FH strategy.

47


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2. Starfield, B. Atenção Primária: Equilíbrio entre necessidades de saúde,

serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde, 2002.

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50


Predicted Tools to Self-evaluation

In the perspective of continuous Quality improvement, five self-eval-

uation tools were developed, aiming different users, gathering a total of

300 quality standards.

The Evaluation for Quality Improvement of the Family Health

Strategy considers two great integrated Analysis Units, also known as

Components: Management and Team. To each of these units, analysis

axes, called Dimensions, were defined. Each Dimension has sub-axes,

or Sub dimensions.

This way, each tool represents an Analysis dimension, adding up

to five possibilities. In its internal structure, according to the subject, each

tool is organized in sub dimensions, covering certain groups of corre-

sponding standards.

The components, or Analysis Units (Management and Team) are

like two big boxes that comprise smaller boxes (Dimensions), which, for

its turn, organize the quality standards according to its theme and attribu-

tion or responsibility. See the general structure of the tools in the table

bellow.

Understanding and Identifying Quality Standards

The quality standards are organized within the Tools (Dimensions) in

Sub dimensions according to its theme and responsibility for the corre-

sponding action.

Appendix

51


Enumeration

In the first column there is the numeration. The standards are numer-

ated according the tool they belong to, from 1 to 5, followed by its se-

quential numeration within the same tool, For example:

1.1 – Tool 1, standard 1





Standard variability according to the population size

During the Pilot testing of the tools it was possible to verify that

some standards from the Management component were more appropriate

to some municipalities according to its size (population). Due to this, the

second column indicates the classification for the tool numbers 1, 2 and 3

according to the size:

BS – Basic Standard: universal applicability, to all Brazilian municipalities.

>20 – Means that the standard is applicable to the municipalities with

more than 20.000 inhabitants

>100 – Means that the standard is applicable to the municipalities with


>500 - Means that the standard is applicable to the municipalities with


52


Components or

Analysis Unit

Tool

(Dimension)

Sub dimension User(who responds)

Implantation/Implementation

Integration of the Service

Network Work Management

Strengthening of the FH

Coordination


Assistance of the FHT

Permanent Education


Normative Actions

FHU Infrastructure and

equipments

Supplies, Immune Biologic

and Medicines

Organization of the work in


Commitment, Humanization,

Responsibility

Health Promotion

Community Participation

Health Surveillance I:

General Actions

Children’s Health


Adult Women and Men’s

Health

Elderly’s Health

Health Surveillance II:

Transmissible Diseases

Health Surveillance II:

Regional Health Problems


Development of the

FH Strategy

Technical Coordination

of the Teams

FH Unit

Consolidation of the

Family Health Care

Model

Health Care

Municipal secretaryof health

FH Strategycoordination

Decision makers for the FHU or itscoordination

All participantsof the FH team

Professionals:Physician, Nurse

and Dental - Surgeon

Management

Team

General Structure of the Tools

53


Notes

54


Evaluation for Quality Improvement of the


Tools, dimensions and sub dimensions

Tool 1: Development of the FH Strategy

Sub dimensions:

I. Implantation and Implementation of the FH in the municipality

II. Integration of the Service Network

III. Work Management

IV. Strengthening of the FH Coordination

Tool 2: Technical Coordination of the Teams

Sub dimensions:

I. Planning and Integration

II. Assistance of the Family Health Team

III. Permanent Education

IV. Evaluation Management

V. Normative Actions

Tool 3: Family Health Unit

Sub dimensions:

I. FHU Infrastructure and Equipments

II. Supplies, Immune biologic and Medicine

Tool 4: Consolidation of the Family Health Care Model

Sub dimensions:

I. Organization of the Work in Family Health Strategy

II. Commitment, Humanization and Responsibility

III. Health Promotion

IV. Community Participation and Social Control

V. Health Surveillance I: General Actions

Tool 5: Health Care

Sub dimensions:

I. Children’s Health

II. Adolescent’s Health

III. Adult Women and Men’s Health

IV. Elderly’s Health

V. Health Surveillance II: Transmissible Diseases

VI. Health Surveillance III: Health Problems with Regional Prevalence


55


ARI: Acute Respiratory Infection

BHT: Buccal Health Team

BMI: Body Mass Index

Ceo-d: average number of deciduous teeth with cavities, extraction

CLT: Labor Laws

CPO-D: average number of permanent teeth with cavities,

lost and with dental restoration

DCA: Dental Clinic Assistant

DH: Dental Hygienist

DV: Domiciliary Visit

FH: Family Health (strategy)

FHT: Family Health Team

FHU: Family Health Unit

G & D: Growth and Development

HCA: Health Care Communitarian Agent

MD: Ministry of Health

HPC: Health Primary Care

IBGE: Brazilian Institute of Geography and Statistics

MHC: Municipal Health Council

MSH: Municipal Secretariat of Health

NA: Nurse Assistant

NB: Newborn

NCHS: National Cadastre of Health Establishments

NGO: non-governmental organizations

ORT: Oral Re hydration Therapy

PC: Primary Care

PC/ FH Coordination: Primary Care/ Family Health Coordination

PE: Permanent Education

PEC: Permanent Education Centers

PSA: Prostate-Specific Antigen

SIAB: Information System of the Primary Care

SSH: State Secretariat of Health

STD/AIDS: Sexually transmitted disease and Acquired Immune

Deficiency syndrome

TB: Abbreviation of tuberculosis

Glossary of abbreviations used in the description of the standards

56


Evaluation for Quality Improvement of

the Family Health Strategy

Tool nº1

Development of the Family Health Strategy

Implantation and Implementation of the Family Health in the Municipality

Q Elementary

1.1 EThe Municipal Plan of Health defines the FH as the

strategy to the reorganization of the Primary Care. ( Y ) ( N )

The standard refers to the definition of the FH as the model for the Primary Care, described in the Municipal Plan of

Health. Being the Plan, simultaneously, a technical and politic instrument, this definition indicates the priority of the

political strategy.

BS

1.2 E

The implantation of the FHS has as a priority the

areas with socio economic conditions less favorable

and or socially excluded. ( Y ) ( N )

The FHS must be implanted focusing the areas and the populations of greater risk and vulnerability within the munic-

ipality, considering the social and sanitary aspect. This standard is related to the search for greater equity and acces-

sibility for the municipal health system.

BS

1.3 EAll teams are responsible for an enrolled population

up to 4.000 people. ( Y ) ( N )

The maximum of people linked to each team must be respected considering that the quality of the actions is affected

by the amount of work. The answer must be affirmative only when all municipal teams are respecting that limit.

BS

1.4 EMunicipal health management feeds the Information

Systems regularly and respects the deadlines. ( Y ) ( N )

This standard evaluates whether the municipal health management is mobilized to the careful treatment of the feeding

of the information systems. Information Systems considered: SIM: Mortality Information System, SINASC: Informa-

tion System on Live Births, SISVAN: Food and Nutrition Surveillance System, SINAN: Reportable Health Events

Information System, SIPNI: Information System of the National Immunization Program, SIAB: Information System on

Primary Care, SIA-SUS: SUS Hospital Information System and CNES: National Cadastre of Health Establishments.

BS

1.5 E Municipal Health Management establishes BH teams( Y ) ( N )

Buccal Health is one of the Ministry of Health for Primary Care priority areas and its integration to the FH strategy can

happen in two ways: integrating the dentist and the DOA to the team, or yet the Dentist, the DOA and the DH. Both

ways are financially supported. To an affirmative answer, consider any number of the BH teams implanted, no matter

the modality.

BS

57


Q Development

1.6 D

Municipal Health Plan details the guidelines and the

planning for the implantation, implementation and

consolidation of the FH. ( Y ) ( N )

It is a higher level comparing to 1.1, meaning that the Municipal Health Plan presents a strategic plan to the reformu-

lation of the assistance model through implantation, implementation and consolidation of the FH strategy.

BS

1.7 D

Municipal Health Management makes an analysis of

the municipality health situation to subsidize the FH

implantation. ( Y ) ( N )

It is a higher level comparing to 1.2, meaning a study to evaluate the health situation in the municipal population

segments, discriminating the epidemiologic profile, the social, environmental and social risks of its regions. Consider

the answer affirmative when the implantation of the FHT is supported by these studies and analyses, being defined a

smaller number of users to the teams responsible for the more critical areas.

BS

1.8 D

The Municipal Secretariat of Health keeps the

strategies of sensitization and presentation of the

FH concerning the population. ( Y ) ( N )

Considering the principles of social participation and social control, the guidelines’ sensitization and the presentation,

goals and characteristics of this health care model to the population and social and organizational networks is impor-

tant. Another goal is to win support and legitimacy for the strategy.

BS

Q Consolidated

1.9 C

Guidelines and planning for the implantation,

implementation and consolidation of the FH are

agreed upon and approved with the MHC. ( Y ) ( N )

The Municipal Health Council is the main center of SUS social control. The participative discussion of planning and

implementation of the FH strategy must be agreed at the MHC to assure its politic, social and community sustainabil-

ity. The standard refers to the guidelines and goals’ agreement, beyond the initial proposal of adhesion at the MH.

BS

1.10 C

Municipal health management keeps analysis and

evaluation of the health situation to subsidize the

FH implementation. ( Y ) ( N )

It is a higher level comparing to 1.7. It means that municipal management, besides having achieved the implantation

basing itself in studies and analysis, keep this performance during the implementation of the strategy.

BS

1.11 C

The Municipal Secretariat of Health keeps the

strategies of sensitization and presentation of the

FH principles to the health professionals of the

municipal network.

( Y ) ( N )

It is a higher level comparing to 1.8. It is necessary that the FH strategy is comprehended by all health professionals of

the services network in order to assure better integration, access and solvability of the health care in the municipality.

BS

58


1.12 CMunicipal health management develops actions in a

way articulated to other government sectors. ( Y ) ( N )

Considering the necessity to articulate and integrate the intervention agendas to the modification of the health determi-

nants, improving the population’s life quality, the proposision of the actions/strategies/projects which involve the

many sectors of the government (intersectional approach) is important.

BS

1.13 C

Municipal health management develops the FH

strategy through the implantation of the BH in the

proportion of one team for two FHS, at least. ( Y ) ( N )

It is a higher level comparing to the 1.5. Consider the answer affirmative when there is, at least, one Buccal Health

Team to two FHS, no matter the modality (Dentist and DOA or Dentist, DH and DOA).

BS

1.14 CMunicipal management monitors the stock and lack

of supplies in the FHU. ( Y ) ( N )

The purchase planning, the stocking regularity, the sensitization of the professionals for the rational usage and control

of the stock aiming error elimination, are considered actions that assure the consolidation of the service quality.

Consider an affirmative answer the existence of spreadsheets or tools for the referred monitoring.

BS

Q Better

1.15 BMunicipal Health management supports and legitimates

popular participation and social control of the FH. ( Y ) ( N )

It is a higher standard comparing to the 1.9. The community leaderships, representatives of the social movements and

MHC itself take part on the strategy’s planning and implementation through local health councils, users’ representa-

tion, among others.

BS

1.16 BThe FH Strategy is institutionalized in the

municipality through a legal instrument. ( Y ) ( N )

The definition of the FH as a care model through a municipal law, decree or other legal instruments assures its legal and

institutional continuity in the politic transitions. It also enables a later proposition of a municipal plan of jobs and

salaries for the FH.

BS

1.17 B

The organization of the FHU teams equilibrates

criteria of regionalization, comfort and sanitary

safety for the development of activities. ( Y ) ( N )

In the municipalities up to 100.000 inhabitants, the FHU must have the maximum of three teams, and in the munic-

ipalities with a bigger number of inhabitants, the FHU must have five teams, at the most. The existence of a technical

responsibility (doctor and nurse) is predicted in a legal norm. This guidance aims to assure quality, according the

criteria of regionalization, access, optimization of the FHU spaces, comfort and sanitary safety for the teams to develop

their work in a proper way. Consider the answer affirmative when all FHU evaluated are according these parameters.

BS

1.18 A

The municipal health management has covenants or

partnerships with organizations of the civil society

and/or social movements. ( Y ) ( N )

Inter-institutional work in its broader definition concerns to articulate actions between public sector and the work

developed by organizations of the civil society aiming to broaden and potentialize initiatives and interventions that

enable life quality improvement.

BS

Q Advanced

59


1.19 A

Municipal Health develops FH strategy implanting

Buccal Health in the proportion of one team to each

FHS. ( Y ) ( N )

It is a higher level comparing to the 1.13. Consider the answer affirmative when there is one Buccal Health Team to

each FHS, no matter the modality (Dentist or DOA or Dentist, DH and DOA).

BS

Integration of the Service Network

1.20 E

Municipal health management enlarges or makes

adjustments in the services network due to the

implantation of the FH in the municipality. ( Y ) ( N )

It is understood by reorganization of the municipal network actions like the enlargement of diagnostic and therapeutic

support’s offer of exams, specialized appointments and hospital beds. Other actions include to reform or build units to

work as a support and reference to the FHU. The answer must be affirmative when any of these actions is happening.

BS

Q Elementary

1.21 D

Municipal health management enlarges or makes

adjustments in the reference network basing itself on

studies about verified and/or estimated demand in the FHS. ( Y ) ( N )

It is a higher level comparing to 1.7, meaning that studies and analyses about the FH demand are performed by

services to subsidize the reorganization of the municipal network. The standard does not refer to the effective assis-

tance of this demand.

S>100

Q Development

1.22 DThere is a programmed offer of basic complementary

exams for the FHS. ( Y ) ( N )

The standard considers as basic exams: blood counts, blood type, urea, creatinine, blood glucose, urine, urine culture,

serology for human immunodeficiency (HIV), serology for syphilis, research of acid-fast bacilli, gynecological pathol-

ogy of uterine cervix, immunologic test for pregnancy, feces parasitological exam. It must be considered: electrocar-

diography, chest x-ray, ultrasonography when it is required. Consider that there is programmed offer in relation to the

demand of the FHS for all the exams listed.

BS

1.23 D

Municipal health management assures the collection

and sending of all serology solicitations for dengue

diagnostic. ( Y ) ( N )

Dengue was chosen for this standard as a condition of quality for the epidemiologic surveillance due to its prevalence

and relevance in Brazil. In epidemic situations, consider the sampling for an affirmative answer.

BS

1.24 C

Municipal health management develops strategies to

assure to the FH teams’ enrolled population reference

for hospitalizations in basic clinics. ( Y ) ( N )

The hospitalization guarantee for the FH enrolled population is fundamental to reinforce the bond, the responsibility,

the trust and the satisfaction. To this tool are considered as basic clinics: Pediatric, Medical Clinic, Gynecology/

Obstetrics and General Surgery.

BS

Q Consolidated

60


1.25 CMunicipal health management assures the high-risk

prenatal care to all pregnant women who need so. ( Y ) ( N )

This standard considers that the assistance occurs, for all the high-risk pregnant women indicated by the FHS, within

the municipality or its network.

BS

1.26 CThere is a programmed offer of cardiology

assistance for the FHS based on demand studies. ( Y ) ( N )

The standard understands that assistance must be based on studies of verified and estimated demand. To the munic-

ipalities that work as regional centers, consider only the assistance of the municipality itself.

BS

1.27 CThere is a programmed offer of orthopedics

assistance for the FHS based on demand studies. ( Y ) ( N )

According the standard the assistance is based on studies of verified and estimated demand. To the municipalities that

work as regional centers, consider only the assistance of the municipality itself.

BS

1.28 C

The proceedings of exams, proceedings and

hospitalizations scheduling occur through a

scheduling center. ( Y ) ( N )

The existence of a scheduling center represents an important step in control, regulation and integration of the services

network. To the small size municipalities, the center may be organized in a fragmented way.

S>100

Q Better

1.29 B

The municipal health manager monitors the

specialized exams required by the FHS not included in

the reference. ( Y ) ( N )

The standard refers to the monitoring of the non included specialized exams, according their relevance, aiming to

improve the offer.

BS

1.30 BThere is a programmed offer in rehabilitation for the

FHS based in demand studies. ( Y ) ( N )

The standard understands that assistance in physical therapy and speech therapy is based in studies of verified and

estimated demand. To the municipalities that function as regional centers, consider only the assistance of the munic-

ipality itself.

BS

1.31 BThere is a programmed offer in ophthalmology for

the FHS based in demand studies. ( Y ) ( N )

The standard understands that assistance is based on studies of verified and estimated demand. To the municipalities

that function as regional centers, consider only the assistance of the municipality itself

BS

1.32 BThere is a programmed offer in otolaryngology for

the FHS based in demand studies. ( Y ) ( N )


that function as regional centers, consider only the assistance of the municipality itself.

BS

61


1.33 BThere is a programmed offer in neurology for the

FHS based in demand studies. ( Y ) ( N )


that function as regional centers, consider only the assistance of the municipality itself

BS

1.34 B

Municipal health management develops strategies to

assure to the FH enrolled population references to

specialized dental areas. ( Y ) ( N )

The standard refers to the offer of specialized dental service, at least, in endodontics, minor oral surgery, periodontics,

assistance to people with special needs and buccal diagnosis emphasizing buccal cancer detection. The current model

to reference services in BH is the Center of Specialized Dental Areas- CEO. The implantation of these units is a priority

for the National Politic of Buccal Health.

BS

Q Advanced

1.35 AThe health services network assures to the FH enrolled

population access to laboratory services of dental prosthesis. ( Y ) ( N )

This service includes its own units, from other municipalities or contracted services. The implantation of Regional

Laboratories of Dental Prosthesis – RLDP is an action planned in the national Politics of Buccal Health.

BS

1.36 AMunicipal health management develops integration

strategies between the Mental Health service and the FHS. ( Y ) ( N )

The municipal management promotes the integration of the Mental Health (MH) to the FH strategy through actions of

health promotion, prevention and assistance. The current model of care to the MH is the constitution of a service

network replacing the psychiatric hospital (Centers for Psycho-Social Care - CAPS, Residential Therapy Service – SRT,

Relocating Program, hospital beds in hospitals and actions in Basic Care) – http://pvc.datasus.gov.br

> 20

1.37 A

Municipal health management monitors the usage

of urgency, emergency and instant attendance

public services by the population under FH. ( Y ) ( N )

This standard enables the evaluation of the solvability, the users’ satisfaction and the effectiveness of the FH work. It

refers to the monitoring of the urgency usage, emergency and instant attendance services as an entrance way to SUS.

S>20

1.38 A

The support given by other professionals to the FH

teams occurs in a systematic way, considering an

established model. ( Y ) ( N )

The standard refers to the support organization for professionals such as pediatrician, gynecologist, clinician, physical

therapist, psychologist, nutritionist, social assistant and for Services like sanitary and epidemiologic surveillance

integrated to the FH, performing health care actions as well as actions of continued education and technical support.

This organization has been called “matrix support”. The answer must be affirmative when at least 50% of the teams

are under this initiative.

S>100

62


Q Development

1.39 DMunicipal health management develops strategies

for the stability of working rights in FH. ( Y ) ( N )

The municipal management has a work plan planning the regularization of the working rights to all FH professionals,

according to the legal instruments.

BS

1.40 DThe MSH criteria for the selection and hiring of FH

professionals are described in an official document. ( Y ) ( N )

There are rules and technical criteria that enable the selection of professionals with the best profile and competence for

FH work. Legal norms such as the demand of the medical register are respected. The answer must be affirmative if

theses criteria comprise the elementary, medium and superior levels.

BS

1.41 C

The criteria for the selection of FH professionals with

college degree valorize the medical residence or post

graduation in Family Health. ( Y ) ( N )

The rules and criteria for the selection of professionals with college degree privilege the post graduation within this

area (Public Health, Family and Community Medicine and Family Health).

BS

Q Consolidated

1.42 B

The entrance of professionals with a college degree

of the FH occurs through a public competition for a

permanent position or public job. ( Y ) ( N )

The Public competition is the main way to incorporate FH professionals. For an affirmative answer consider that 80%

or more of the professionals with a college degree of the FH have a permanent position or public job.

BS

Q Better

1.43 B

The entrance of professionals with a technical degree of theFH occurs through a public competition for a permanentposition or public job. ( Y ) ( N )

The Public competition is the main way of incorporating professionals of the FH. For an affirmative answer consider

that 80% or more of the professionals with a technical degree of the FH have a permanent position or public job.

BS

Q Advanced

1.44 AThe FH professionals with a college degree have

been working in the municipality for over two years. ( Y ) ( N )

The stability of the professionals in the FH strategy broadens the possibilities of continuity, bond and responsibility.

To an affirmative answer consider 80% or more of the professionals in this situation.

BS

1.45 AThe HCA have been working in the municipality for

over two years. ( Y ) ( N )

The stability of the professionals in the FH strategy broadens the possibilities of continuity, bond and responsibility.

To an affirmative answer consider 80% or more of the professionals in this situation.

BS

Work Management

63


Strengthening of the FH Coordination

1.46 A

Municipal management has a program of incentives

for the FHS related to performance, goal achievement

and results obtained. ( Y ) ( N )

The successful initiatives of professionals, teams or units are recognized and awarded annually by the coordination,

considered some defined criteria.

BS

1.47 AMunicipal health management has career plans, positions

and institutionalized salaries, concerning the FH. ( Y ) ( N )

There are legal instruments, instituted by the municipal government, for the professional career and progression of the

health workers, concerning the FH professionals. Only if the three levels (superior, medium and elemental) are achieved,

the answer to the standard must be affirmative.

BS

1.48 A80% of the professionals with a college degree have

a specific formation within this area. ( Y ) ( N )

Consider as professionals with a college degree of the FH teams: physicians, nurses and dental surgeons. Consider as

a specific formation within this area: specialization in Family Health, Public Health, Preventive and Social Medicine,

Residence in Family and Community Medicine, Specialization in Preventive and Social Dentistry, Public Buccal Health.

The standard points to the efforts developed by the management for the qualification of its professionals.

BS

1.49 E The MSH has a specific coordination for the PC/FH.( Y ) ( N )

The municipal management designates a professional or team to perform the coordination of the PC and or FH strategy

in the municipality. The standard considers exclusive dedication to this activity, the professional not being involved in

the assistance.

BS

Q Elementary

1.50 D

The PC/FH coordination is inserted in the organizational

structure of the Municipal Secretariat of Health. ( Y ) ( N )

The standard refers to the position of FH coordination being legally established. Consider the answer affirmative when

the sector of PC and/or FH is represented in the MSH organizational chart. These aspects indicate the institutional

legitimacy of the coordination.

BS

Q Development

1.51 C

Municipal health management concerns PC/FH

coordination in the process of settlement of the

indicators of the Primary Care settlement. ( Y ) ( N )

Considering the relevance and the impact of this action, the PC/FH coordination must take part on the settlement, with

no delegation or transfer of responsibility.

BS

Q Consolidated

1.52 B

Municipal management enables the participation of

the PC/FH coordination in professional congresses

and encounters. ( Y ) ( N )

The standard refers to municipal management enabling and encouraging the participation of the PC/ FH coordination

members, at least once a year, in technical and scientific events concerning the FH area, such as: sampling, encoun-

ters, Public Health congresses, Family and Community Medicine and Family Health.

BS

Q Better

64


1.53 BThe technician(s) responsible for the PC/FH

coordination have a specific formation within this area. ( Y ) ( N )

The standard refers to the universe of technicians with a college degree involved in the coordination of the PC/FH in

different areas of the system (central, regional, districts and FHU) have a post graduation in Public Health, Family and

Community Medicine, Family Health or Administration and Management. To an affirmative answer consider 50% or

more of the professionals in this situation.

>100

1.54 B

The coordination of the PC/FH is composed of a

multi professional team for the support, supervision

and technical supervision of the FHS. ( Y ) ( N )

This standard refers to the existence of a group composed by various health professionals, including professionals of

health surveillance, responsible for the technical supervision of the FHS.

>100

1.55 BThere is a decentralized coordination responsible by

the assistance of, at most, 8 FH teams. ( Y ) ( N )

In municipalities of a greater size the assistance to the teams has to be decentralized, assuring a closer technical and

management support to groups up to 8 teams. The coordination actions may be performed by a technician of the FHU,

of the districts or shared by a regional coordination team.

>100

1.56 BThe MSH has a professional responsible for the BH

area in the PC/FH coordination. ( Y ) ( N )

The coordination must, ideally, be integrated by professionals with a college degree of the BH aiming to assure the

specificities and relevance of the actions.

>100

1.57 A

Municipal health management and/or coordination

establish or use mechanism for the monitoring of the

level of the FH users’ satisfaction. ( Y ) ( N )

The standard refers to municipal health management or the coordination establishing or using methods and tools to

monitor the level of users’ satisfaction. Consider the answer affirmative when this action is achieved in a systematic

way, to all FHU (or sampling for the municipality), every two years (or less).

BS

Q Advanced

1.58 ATechnical areas work in an integrated way with the

PC/FH coordination. ( Y ) ( N )

The professionals of the technical areas, such as: Children Health, Women Health, Mental Health, Epidemiologic

Surveillance, Sanitary and Environment Surveillance work together with the PC/ FH coordination in the development

of technical materials, politics and actions of assessment and supervision of the FHS.

>100

1.59 AThe PC/ FH coordination support and promote the

formation of Local Health Councils in the basic units. ( Y ) ( N )

The Local Health Councils or Unit Councils (FHU or Family Basic Unit), when active and well formed, are a scaffolding

for the ascendant development of the decisions related to the municipal health. It is the main role of the manager to

promote, support and assure its constitution in all health units.

BS

1.60 A

Municipal health management develops, together

with PC/ FH coordination and other technical areas of

the MSH, a Humanization politics for the municipal

net, including the FH. ( Y ) ( N )

In order that the teams are able to develop effective and systematic actions of Humanization, Commitment and Respon-

sibility, it is fundamental that the guidelines and the mechanisms of the implementation are established from the MSH

as politics for the municipal network.

BS

65


Notes

66




Tool nº2

Technical Coordination of the Teams


Q Elementary

2.1 EThe PC/ FH coordination has a schedule of visits to

the FHU and meetings with the FHT. ( Y ) ( N )

The schedule is a basic tool in the organization of the coordination work where the systematic and regular follow up

of the FHS is planned.

BS

2.2 DThe PC/ FH coordination has a working plan guiding

the activities to be developed. ( Y ) ( N )

The standard refers to a working plan establishing the competences of the coordination, the actions to be developed,

priorities, goals, deadlines and the decision makers. Consider for the affirmative answer the existence of a document

penned every two years.

BS

2.3 D

The PC/ FH coordination registers the follow up of

the FH situation in the municipality: number of

teams, coverage, professionals and results. ( Y ) ( N )

The work of the FHT is monitored about its coverage, production, goals achievement and indicators contained in the

ISPC. This must be updated at least every three months.

BS

2.4 CThe PC/ FH coordination regularly takes part in the

meetings of the Municipal Health Council. ( Y ) ( N )

The standard considers the participation of the Coordination members in most Council meetings as possible, prefera-

bly, in 50% of the meetings. In the big size municipalities it is considered for an affirmative answer the participation in

District or Local Councils.

BS

2.5 CThe PC/ FH coordination get together with the

public and social sectors of the municipality. ( Y ) ( N )

The standard points to the development of the intersectional approach and strengthening of the FH. Consider the

meetings with the government sectors related to health, education, social assistance, environment and sanitation, as

well as local organizations and social movements. The meetings must involve planning, execution and/ or evaluation

of the actions. The answer must be affirmative when the meetings with one or more of the refereed sectors happen

every three months.

BS

Q Development

Q Consolidated

67


2.6 C

The PC/ FH coordination has and makes available for

the FHT an updated register of the municipality

social resources. ( Y ) ( N )

The standard refers to the research, systematization and presentation for the FHS of the main services of social

assistance, public utility, citizen assistance, consumer law and NGO of the municipality.

BS

2.7 BThe municipal experiences with the FH are presented

in related congresses and encounters. ( Y ) ( N )

The standard considers, for an affirmative answer, one or more presentations per year. In municipalities over 500.000

inhabitants, it must be considered one annual presentation per health region/district.

BS

2.9 DThe PC/ FH coordination get together every month

with the FHT. ( Y ) ( N )

A higher level comparing to 2.1, where there are guaranteed mensal meetings of the members of the team with the

coordination, with established subjects and agenda.

BS

2.10 CThe PC/ FH coordination assures to the FHT a

weekly shift destined to team meeting. ( Y ) ( N )

It is understood as the dedication of 4 hours per week to the team meeting to aim the planning, evaluation, integration

and knowledge exchange. The coordination is sensitized to the importance of this activity and gives the necessary

support.

BS

Q Better

2.8 B

The PC/ FH coordination develops initiatives of integration

and partnership with academic institutions, enabling the

realization of scientific production within Primary Care. ( Y ) ( N )

The standard points to the technical body with the capacity to formulate, reflect and interact with the aca-

demic institutions, promoting a knowledge/practices exchange and enabling the production of knowledge

within this field.

>100

Assistence of the FHT

Q Development

Q Consolidated

2.11 CThe PC/ FH coordination uses tools to the follow up

of the actions and practices of the FH. ( Y ) ( N )

It means that the coordination develops or uses tools, such as: spreadsheets, graphs and indicators to follow up the

performance of the FHT, enabling some comparative and temporal analyses, among others.

BS

68


2.12 CThe PC/ FH coordination develops strategies to

administrate conflicts between FH professionals. ( Y ) ( N )

It means that eventual conflicts and relationship problems in the work environment constitute a care focus for the

coordination, which tries to solve them in a positive way, enabling the opening of communicative channels and the

improvement of the FHT work environment.

BS

2.13 C

The PC/ FH coordination evaluates the level of satisfaction

of the professionals with the work and takes into account

criticisms and suggestions in action planning. ( Y ) ( N )

The coordination performs a formal process of evaluation of the level of satisfaction of the professionals, dedicating

special care to participative and ascendant management, enabling the opinions of the FHT to be internalized in the

daily work routine.

BS

2.14 B

The PC/ FH coordination develops together with the

teams strategies for facing the problems found in

the care of the population. ( Y ) ( N )

The problems faced by the FHT are followed up by the coordination, which takes the necessary measures to solve

them, specially the ones which hinder the quality of the client care.

BS

Q Better

2.15 A

The PC/ FH coordination develops, together with the

teams, tools for the organization and monitoring of

the actions and practices of the FHT. ( Y ) ( N )

A more advanced level compared to 2.11. It means that the evaluations of the FH works happen in a participative way,

enabling the sharing of the management decisions and the exchange in the formulation or proposal of the tools used

in the monitoring.

BS

2.16 DThe PC/ FH coordination offers preparatory courses

to the FH workers. ( Y ) ( N )

The coordination prepares and executes (or joins other areas to do so) courses or encounters to discuss principles,

guidelines and the work dynamic of the FH with the strategy workers.

BS

2.17 D

The PC/ FH coordination regularly takes part in

forums or encounters to the development of the

Permanent Education. ( Y ) ( N )

The standard refers to the direct participation of the coordination members in local or regional activities related to the

development of permanent education actions. Consider the maximum regularity possible, according the proposed

schedule of encounters.

BS

Q Advanced

Permanent Education

Q Development

69


2.18 C

The PC/FH coordination decides together with the

FHT the themes and activities to be developed in

the Permanent Education. ( Y ) ( N )

There is an active participation of the professionals in the proposal of themes considered priority or necessities

concerning permanent education.

BS

2.19 B

It is offered theoretical and practice formation in the

basic areas to the FH professionals with a college

degree who need so. ( Y ) ( N )

The coordination organizes theoretical and practice formation in the health basic areas (children, women, hypertension

and diabetes, buccal, mental, sanitary surveillance, epidemiologic and environmental etc) to physicians, nurses and

dentists who require or demonstrate lacks in its formation concerning the theme.

BS

Q Consolidated

2.20 B

The technical areas and the FH develop, in an

integrated way, Permanent Education activities. ( Y ) ( N )

The standard evaluates the effective and systematic participation of the technical areas of the MSH in the actions of

permanent education developed by the PC/ FH coordination, supporting and making viable activities like the ones

described at the standard 2.19.

>100

Q Advanced

2.21 AThe PC/FH coordination enables the specialization

within the area for the FHT professionals. ( Y ) ( N )

A more advanced level comparing to 2.19. There is a guarantee of specialization for the FHT professionals, obeying

the technical criteria for priority such as time in service, interest, worthiness etc.

BS

2.22 EThe coordination evaluates the production of the

FHT every month. ( Y ) ( N )

Although the FH develops actions in a way different from the logic by proceedings, based in the population and the

territory, the evaluation of the team production is the most elementary action for the follow up of the developed actions

results.

BS

2.23 D

The PC/ FH use the information of the ISPC as a

management tool: evaluation, planning and monitoring.( Y ) ( N )

The SIAB analysis works as a decision maker and is used for action improvement, in a systematic and regular way, by

the coordination.

BS

Q Elementary

Q Better


Q Development

70


2.24 DThe PC/ FH coordination analyses every month the

SIAB reports together with the FHT. ( Y ) ( N )

The SIAB analysis and its utilization as a planning and management tool occur with the teams’ participation.

BS

2.25 CThe PC/ FH coordination analyses data and reports

of the SUS information systems or in health. ( Y ) ( N )

Every six months, analyses of the health situation and of the FH/ PC development are made using the data available at

the Information Systems: SIM: Mortality Information System, SINASC: Information System on Live Births, SISVAN:

Food and Nutrition Surveillance System, SINAN: Reportable Health Events Information System, SIPNI: Information

System of the National Immunization Program, SIAB: Information System on Primary Care, SIA-SUS: SUS Hospital

Information System and CNES: National Cadastre of Health Establishments.

BS

Q Consolidated

2.26 C

The PC/ FH coordination elects criteria and indicators

to evaluate the teams and the impact in the

population’s health condition. ( Y ) ( N )

The teams are involved in the analysis of the actions impact, using different indicators, or more specific ones, compar-

ing to the ones that exist at the SIAB. The answer must be affirmative if this process is performed, at least, once a year.

BS

2.28 BThe PC/ FH coordination debates the results and

plans the FH goals with the teams. ( Y ) ( N )

The PC/ FH planning is preceded by an evaluation with all the FH professionals, as well as a settlement of the

performance and coverage goals, among others. This process must occur, at least, every six months.

BS

2.29 B

The PC/ FH coordination gets together with the others

MSH areas to debate the results obtained within the PC. ( Y ) ( N )

The results of the teams’ work are presented and debated with the other sectors of Municipal Health, evaluating the

actions’ impact and the health profile. This standard is different from 2.5 where the focus is the development of the

intersectional approach, legitimacy and support. Consider, to an affirmative answer, that there are formal meetings in

order to achieve this goal, at least, every six months.

BS

2.27 C

The coordination analyses the demand of exams and

guidance from FH observing if it fits the estimated

necessity. ( Y ) ( N )

This is about the existence of a management mechanism to evaluate whether the amount of exams and guidance

required by the FHT fits the client profile according the technically defined necessities.

BS

Q Better

71


2.30 A

The PC/FH evaluates the goals established for the

Settlement of Indicators of the Primary Care with

the FHT. ( Y ) ( N )

The coordination debates with the teams the proposed goals for the Settlement of Indicators of the Primary Care and

monitors their goals, at least, every six months.

BS

2.31 ABuccal Health Epidemiologic epidemiologics

inqueries are gathered in the municipality. ( Y ) ( N )

The standard considers the minimum periodicity of four years to the realization of this kind of epidemiologic study.

>20

Q Elementary

2.32 EThe PC/ FH coordination makes available to all FHT a document

with the principles and guidelines of the FH strategy. ( Y ) ( N )

The coordination has a written document with the principles and guidelines of the FH, and this document is available

and accessible to all FHU professionals.

BS

Q Advanced

Normative Actions

2.33 EThe PC/ FH use the written norm about facilities and

equipment. ( Y ) ( N )

It refers to the use of updated technical documents, regulations of sanitary surveillance (formulated by the federal,

state or municipal areas) concerning the establishment of a norm for the facilities and equipments of the FHU.

BS

Q Development

2.34 D

The PC/ FH coordination makes available to all FHT

updated information from the municipal reference and

counter reference system. ( Y ) ( N )

There is information in all FHU, such as: documents, instructions, flowcharts, services list, guiding criteria or

standardized behaviors, written, updated at least every six months, about the municipal reference and counter

reference system.

BS

2.35 DThe PC/ FH coordination makes available a manual of

basic pharmacy medicine. ( Y ) ( N )

There is a manual, formulated by MSH itself or by other management area (state or federal), about the medicine used

in the basic pharmacy. Consider, for an affirmative answer, that all teams have this material.

BS

72


2.38 BThe PC/ FH coordination has a document

establishing the conduct of each FH professional. ( Y ) ( N )

It refers to the existence, in the units, of a document or instruction paper, formulated by the MSH itself or another

related area, establishing the conduct of each FH professional category concerning actions, behavior, procedures and

activities (DOA, HCA, nurse assistants, dental surgeons, nurses, physicians and DH).

BS

2.39 B

The PC/ FH coordination makes available to the FHT/

BH protocols and technical information about the

approach in urgent situations. ( Y ) ( N )

There are manuals, routines, documents and protocols which guide and establish, in a technical perspective, the

urgency assistance.

BS

Q Better

2.36 C

The PC/ FH coordination makes technical scientific

support material about frequent situations in Primary

Care available to the teams.

Textbooks, manuals, technical reports or memorandum about sanitary risks, illnesses or monitoring situations frequent

in PC are provided by the coordination to the FH professionals. This material does not refer to the informative material

destined to the users.

BS

Q Consolidated

2.37 C

The PC/ FH coordination makes technical scientific support

material about the infectious and parasitic diseases of

greater incidence in the country available to the team. ( Y ) ( N )

There are textbooks, manuals, technical reports or memorandum provided by the coordination to the FHU profession-

als. It is not being considered the informative material destined to the users.

BS

Q Advanced

2.40 A

The PC/ FH coordination makes available to the FHT/

BH protocols and technical information about the

approach in Mental Health urgency situations. ( Y ) ( N )

There are manuals, routines, documents and protocols which guide and establish, in a technical perspective, the

urgency assistance in Mental Health, specifically.

BS

73


Notes

74




Tool nº 3

Family Health Unit

FHU Infrastructure and Equipment

Q Elementary

3.1 E

Each FHT has an consulting room with basic

equipments to population assistance. ( Y ) ( N )

Basic Equipment to FH consulting room: gynecologic table, stethoscope, tensiometer, thermometer, standard view-

box, lantern, rules for measuring children, tape measure, Pinard stethoscope, gynecologic swab of different sizes,

focus, otoscope, as well as conditions for frequent hygiene of the hands and infantile and adult scales (these last items

may serve for more than one clinic).

BS

3.2 E

The FHU consulting room enable visual and auditive

privacy of the medical consultations. ( Y ) ( N )

The standard refers to the medical consultations not being able to be heard or viewed by people who are in a room

adjacent to the location of the consultation, assuring ethics, privacy and secrecy. This can occur in many ways,

according to the local conditions.

BS

3.3 E

The consulting room where gynecologic exams are

performed must have, at least, a private dressing

place. ( Y ) ( N )

This privacy may be assured according the existing conditions. It is fundamental that the gynecologic consultations

occur in a humanized environment, respecting the principles of privacy and inviolability, besides the cultural references

of the users.

BS

3.4 E The HCA have basic equipments for external work.( Y ) ( N )

Basic equipment for HCA: it is recommended that they have, at least, a vest or t–shirt, a clipboard, briefcase or

backpack, cap, pencil, pen. The answer must be affirmative when there are available basic materials in all HCA of the

FHU.

BS

3.5 E

The FHT have complete equipment and dental

instruments to the regular performance of its

activities. ( Y ) ( N )

The standard refers to the equipment composed by compressor, patient chairs, reflector, auxiliary unit with a cup

stand for waste container and/or suction system, equipment with holder for multifunction syringe and two handpieces,

foot control to activate the equipment, dental stool, amalgamator, photopolymerizer, sterilizer or autoclave and equip-

ments of individual protection (EIPs). Consider also the necessary instruments to attend the expected demand. The

basic list of equipments, instruments and input is published in the project website: http://dtr2002.saude.gov.br/

proesf/autoavaliacaoesf/index.htm (click on Technical Proposal, then go to Technical Areas and then Buccal Health).

BS

75


3.6 E

Considering physical installations, the FHU has, in

all rooms, adequate conditions to the development

of basic health actions. ( Y ) ( N )

The standard refers to illumination, ventilation, floor, walls and ceiling conservation, hydraulic installations, electric

installations, doors, windows, glasses and fire extinguisher, according the sanitary rules (physical installations, equip-

ments and procedures) existing to the basic health units.

BS

3.7 E

The FHU has a covered space destined to be a

reception and waiting room, with a number of seats

according the expected demand. ( Y ) ( N )

This standard refers to a space in the FHU destined to the waiting of the users, making it possible for the users who

arrive during the first hour after the opening of the unit to stay seated. The kind of seat may be of different types,

according the local culture.

BS

3.9 D

The FHU programs the use and suitability of the

places to the realization of curatives, inhalations,

suture and patient observation. ( Y ) ( N )

The standard, when using the expression “use and suitability” of the places, refers to the current understanding of the

HD that the spaces in the FHU may be multi functional, as long as the rules for its functioning are respected.

BS

3.10 DThe gynecological obstetric equipments are in

sufficient number for the work of the FHT. ( Y ) ( N )

The FHU has instruments and materials for the gynecological obstetric assistance in enough quantity and sterilized

conditions for the expected demand (enough not to cause interruptions or damages to the assistance). Instruments:

small, medium and big swabs, Pozzi pincer, Cheron pincer, auxiliary pincer, tubs. Consumable materials: gloves,

cotton, gauze, acetic acid, compress, alcohol, lugol, fixer solution, microscope slide for cytology, Ayre spatula and

endo cervical brush.

BS

Q Development

3.11 C

The number of FHU consulting room enables the

simultaneous work of the FH doctors and nurses.( Y ) ( N )

The standard refers to the existence of consulting room with basic equipments (3.1) in enough number so that the

doctors and nurses of the FHT are able to perform patient care concomitantly and without interruptions in any working

period of the FHU.

BS

3.8 E

The FHU has a refrigerator destined only to vaccines

with temperature control to the immune biological

preservation. ( Y ) ( N )

This piece of equipment reserved only to the exclusive use of immunization activity with temperature control is

considered quality a Primary Care quality criteria.

BS

Q Consolidated

76


3.12 CThe tensiometers and scales of the FHU are

balanced according technical parameters. ( Y ) ( N )

Consider the answer affirmative when balancing and maintenance of these equipments occur, at least, every six

months.

BS

3.17 CThe FHU has other equipment to teams’ assistance.

( Y ) ( N )

The standard refers to the existence in the FHU of an electrocardiograph and opthalmoscope as equipments that enable

an increase in the PC resolubility.

BS

3.13 C The HCA has other equipment for external work.( Y ) ( N )

Among this equipment may be: shoes, sunscreen, umbrellas and parasols.

BS

3.14 C The FHU has a telephone line.( Y ) ( N )

It is a phone line belonging to the FHU, not including public telephones or employees’ cell phones.

>100

3.15 C The FHU has a computer set.( Y ) ( N )

The FHU must have a set composed by, at least: a tower, monitor, keyboard, mouse, stabilizer and printer that are

compatible and in good conditions, as well as the necessary supply for its functioning (paper, ink cartridges).

>100

3.16 C

The FHU has a room reserved for team meetings,

internal activities of the HCA and Continuing

Education activities. ( Y ) ( N )

This room may be of multiple and alternate use, however it must be destined only for these activities. This room may

be made possible in different ways, according the local conditions.

BS

3.18 CThe FHU has equipment for a first care in urgencies

and emergency situations. ( Y ) ( N )

The standard refers to the FHU having: ambu, masks, guedel airway, gelco for bodking of vessels solutions for

parenteral hydration and basic medicine to use in cardiac arrest.

BS

77


3.19 C

The transport of the FH professionals to

programmed external activities occurs in a MSH

vehicle. ( Y ) ( N )

The answer must be affirmative when there is a MSH vehicle available to the assistance of the external activities

programmed by the FHT.

BS

3.21 C

The dental clinics enable the DH and dental surgeon

to work in an integrate way.( Y ) ( N )

The physical disposal of the clinics, equipments and instruments (listed in 3.5) enables the concomitant assistance by

the dental surgeon and the DH, in an integrated way.

BS

3.22 B

The FHU is equipped to assist people with special

needs: ramps, handrail, door width, bathrooms,

wheelchair.( Y ) ( N )

Even though these structures are fundamental in any FHU, their existence qualifies as assistance care, broadening the

access, equity and resolubility of the PC.

>100

Q Advanced

3.24 AThe rooms where the gynecological exams occur

have their own bathroom. ( Y ) ( N )

This standard refers to the ideal conditions for gynecological assistance, considering the client’s comfort and privacy.

BS

Q Better

3.20 CThe FHU has electronic equipments to educational

activities. ( Y ) ( N )

The standard refers to presence of a television, videocassette and/or DVD and a sound system.

BS

3.23 A

The FHU has internet access and makes it available

to the FH workers according defined criteria.

( Y ) ( N )

Internet is considered as an important resource for communication, obtainment of technical information and technical

update (continuing education). The broadband internet in the FHU, available to the FH workers (with criteria) is an

important quality brand of the PC.

>100

78


3.27 EThe FHT/FH has materials and supplies for the

performance of educational activities with the population. ( Y ) ( N )

The standard considers that minimum supplies to educational health activities are cartridge paper or similar, atomic

brushes, string, glue, scissors, albums.

BS

3.26 E

The FHU supplies on a regular basis and in enough

quantity basic medicines prescribed in the treatment

of the most frequent parasitic infections. ( Y ) ( N )

The standard refers to the supply of these medicines, covering the needs of 80% of the territory, in a regular frequency

and programmed in a way that shortages are eventual and do not compromise the resolubility of the treatment. It may

be calculated through the non assisted demand.

BS

3.28 E

The FHU supplies in a regular basis and in enough

quantity medicines prescribed in the prevention and

treatment of deficiency anemia and hypovitaminosis. ( Y ) ( N )

When using the expression “on a regular basis and in enough quantity”, the standard refers to the supply of these

medicines, covering the needs of 80% of the territory, in a regular frequency and programmed in a way that shortages

are eventual and do not compromise the resolubility of the treatment. It must provide the assistance to pregnant

women and children.

BS

Q Development

3.29 D

The FHU has basic supplies in enough quantity for

the regular development of the health actions.( Y ) ( N )

Consider as basic supplies: cotton, gauze, sticking plaster, syringe, proceeding glove, thread for suture, bandages,

tongue depressor, thermometer, inhalation masks. Eventual interruptions in the supply that do not disturb the continu-

ity and quality of the care should not be considered.

BS

3.25 E

The FHU performs, routinely, all vaccination in the

basic schedule of the National and State

Immunization programs. ( Y ) ( N )

For the National program consider the definitions of the Secretariat of Health Surveillance, Ministry of Health: http://

dtr2001.saude.gov.br/svs/imu/imu02.htm

BS

Q Elementary

Supplies, Immune-biologic and Medicines

79


3.30 DThe FHU has BH supplies in enough quantity to the

development of the actions on a regular basis. ( Y ) ( N )

Eventual interruptions in the supply that do not disturb the continuity and quality of the care should not be considered.

BS

3.31 D

The FHU has printed material in enough quantity to

the regular development of the health actions.( Y ) ( N )

For instance: application blank, prescriptions and requirements. Eventual interruptions in the supply that do not

disturb the continuity and quality of the care should not be considered.

BS

3.33 D


quantity antibiotics prescribed in the treatment of the

most frequent infectious diseases, present in the

MSH antibiotic standardised list ( Y ) ( N )

The standard refers to the supply of the antibiotics used in Primary Care. Covering 80% or more of the territory needs,

in a regular and programmed frequency, in a way that the shortages are eventual and do not compromise the resolu-

bility of the treatment.

BS

3.32 DThe FHU has glucometers and tape supply in

enough quantity. ( Y ) ( N )

Equipment and input considered indispensable in the care of the diabetic population. Consider, for the tapes, adequacy

of 80% of the demand.

BS

3.34 D


quantity the basic medicine prescribed in the

treatment of systemic hypertension. ( Y ) ( N )

The standard refers to the supply of these medicines, covering 80% or more of the territory necessities, with regular

and programmed frequency in a way that shortages are eventual and do not compromise the resolubility of the

treatment.

BS

3.35 D


quantity the basic oral medicine prescribed in the

treatment of diabetes mellitus. ( Y ) ( N )

The standard refers to the supply of these medicines, covering 80% or more of the territories necessities, with regular


treatment.

BS

80


3.37 C

The FHU has the basic medicine prescribed in the first

care of patients with hypertensive crisis according the

local protocols, stored in adequate conditions.

( Y ) ( N )

The standard considers the medicines defined in clinical protocols, in enough quantity to meet the specified demand.

The existence of this resource contributes to an increase of the PC resolubility.

BS

3.38 BThe FHU has inhalation medicines for asthmatic

crisis, stored in an adequate place. ( Y ) ( N )

Attend 100% of the demand. The existence of this resource contributes to an increase of the PC resolubility.

BS

Q Better

3.39 B

The FHU has medicine to the treatment of

gastrointestinal diseases. ( Y ) ( N )

The standard refers to the supply of these medicines, covering 80% or more of the territories necessities, with regular


treatment

BS

3.40 A

The FHU has the basic medicine prescribed in the

first care of patients with epileptic crisis according

the local protocols, stored in adequate conditions

( Y ) ( N )

Attend 100% of the demand. The existence of this resource contributes to an increase of the PC resolubility.

BS

Q Advanced

Q Consolidated

3.36 C

The FHU supplies on a regular basis and in enough

quantity NPH insulin to the treatment of diabetes

mellitus, out of proper storage in a refrigerator.

( Y ) ( N )

The standard refers to the supply of these medicines, covering 80% or more of the territory necessities, with regular


treatment

BS

81


Notes

82




Tool nº 4

Consolidation of the Family Health Care Model

Organization of the Work in the Family Health Strategy

Q Elementary

4.01 E The registry of families is updated every month.( Y ) ( N )

The standard refers to the fact that the families within the area are visited every month, enabling the updating of the A

file card from ISPC.

4.02 EThe domiciliary visit is a systematic and permanent

activity of all FHT members. ( Y ) ( N )

In the FH strategy DV is considered a fundamental action, which must be developed by all team professionals in an

integrated and complementary way. Through the DV, the team can get to know the community better, the risks

associated with the territory, broaden the bond and identify the cases that need domiciliary care such as patients that

need to stay in bed or patients with special needs. It is recommended that the doctor and the nurse dedicate at least

four hours a week, each, toward accomplishment of this activity.

4.03 E The FH unit works every weekday, in two shifts.( Y ) ( N )

The standard refers to the FH unit working with care assistance at least eight hours per day.

4.04 E

The team develops permanent actions of clarification to

the population about the FH strategy characteristics. ( Y ) ( N )

The standard refers to the FHT acting together with the community, in a permanent and systematic way (at least once

every three months), clarifying the characteristics of the FH model in use in that area.

Q Development

4.05 D The FHT uses the ISPC information for the work planning.( Y ) ( N )

The standard refers to the usage of the information in the file card A from ISPC to the planning of the FHT work:

population, age group, diseases and living conditions, among others.

4.06 D

The FHT works with a map of its acting area where the micro

areas under the HCA’s responsibility are distinguished. ( Y ) ( N )

The map of the FHT actuation area, distinguishing the micro areas under the HCA’s actuation, is one of the most

important initial actions to the structuring of team work in relation to its territory.

83


4.07 D

The team makes a diagnosis of the population’s health

situation, identifying the most frequent problems. ( Y ) ( N )

The standard refers to the gathering of information in the file card A (ISPC) associated to the mapping of the risky areas

and interviewing community leaderships. Other sources of information can be the IBGE, health information systems

and press data.

4.08 D

Domiciliary Care is planned considering the indications for

the actuation of the FHT professionals. ( Y ) ( N )

The standard refers to the existence of a planning in domiciliary care considering professional specificity and the need

of intervention, searching to improve and integrate the performance of the team professionals with a college degree.

4.09 D

The handbooks are organized by familiar nucleus,

strengthening the FH care model. ( Y ) ( N )

The standard refers to the organization of the familiar handbook in which there are the individual handbooks. These

may be organized by micro area. This way of organization may be developed in the cases of computer handbooks.

Q Consolidated

4.10 C

The FHT has registers of various aspects of the territory

and its population. ( Y ) ( N )

It is a more advanced level compared to 4.5, showing a more profound analysis on the health situation of the families

and people of the territory. The team aims to know and register demographic, socioeconomic, ethnic, cultural, environ-

mental and sanitary aspects of the enrolled area.

4.11 C

The activities schedule is defined by the team members

altogether and is based on the analysis of the area health

situation. ( Y ) ( N )

It is a more advanced standard comparing to 4.3, showing that a work process is being improved: the team members

gather to formulate the schedule and use the data of the analysis of the territory health situation, arranging the time and

the kind of activity to be developed according the profile.

4.12 C

The FHT registers and monitors the references to other

care levels. ( Y ) ( N )

The guiding to the references (specialized cares) is systematically registered in another medium besides the medical

handbook, enabling flow monitoring: assisted/non assisted cases, waiting time and return of the information to the

units (counter reference). The answer must be affirmative when the proposed actions are contemplated: register and

follow up.

4.13 C

The FHT registers and monitors requirements of

diagnostic exams. ( Y ) ( N )

The requirement of exams is systematically registered in another medium besides the medical handbook, enabling flow

monitoring: assisted/non assisted cases, waiting time and return of the information to the units (counter reference).

The answer must be affirmative when the proposed actions are contemplated: register and follow up.

4.14 C

The FHT notifies the users about scheduling of

specialized appointments and or exams. ( Y ) ( N )

The standard refers to the team professionals locating and communicating, directly to the users, the time and place of

the exams and appointments that were scheduled by the team.

84


Q Better

4.15 CThe FHT dedicates a part of the week for the team meeting.

( Y ) ( N )

The standard refers to a period up to four hours per week that the team dedicates to a meeting with all it’s the

members, with or without the coordination. The goal of this activity is to discuss the cases, the actions planning,

evaluations, conflicts resolution and knowledge exchange. To the teams that assist country areas, the standard

considers two monthly meetings of four hours each.

4.16 C

The FHT dedicates a monthly meeting to the evaluation of the

results reached and the planning of the continuity of the actions. ( Y ) ( N )

The standard refers to the FHT dedicates one of its meetings every month, with or without the coordination, to the

evaluation of the results reached and the planning of the continuity of the actions. The standard does not consider the

meetings dedicated to the operationalization of the data to the ISPC, in which evaluation and planning actions are not

included.

4.17 B

The FHT monitors the search for the types of service

being required, verifying the assistance percentage. ( Y ) ( N )

The FHT studies the flow of assistances in the FHU making a register and monitoring the search for kind of care

(consultations of children, women, hypertenses, exams, procedures and others), verifying the assistance percentage

of the demand.

4.18 B

The maps of the team work are updated and show

dynamics situations of the territory and its population. ( Y ) ( N )

It is a higher standard comparing to 4.6. Besides the areas under the HCA’s responsibility, the FHT work maps

distinguish the main community resources, the regions of greater vulnerability/risk, follow up of epidemiologic situa-

tions, among other things. It indicates the perfecting of the work with more dynamic and informative maps, the live

maps.

4.19 B

The FHT works the diagnosis, the planning and the realization

of the actions for the territory in an integrated way. ( Y ) ( N )

The standard comprehends that the members of the FH and BH teams develop actions of analyses of the health

situation, planning and intervention together with the population, in an integrated and complementary manner.

Q Advanced

4.20 A

The FHT organizes a “situation panel” with maps, data

and health information of the territory. ( Y ) ( N )

The standard refers to a resource of organization and planning also known as health scoreboard, health panel or yet

billboard or situation room, depending on the region. It consists in a mural or panel in an accessible place, in which the

FHT has the data, information and even maps of the region and of the team work, enabling visual follow up by the

professionals and the community. Consider for an affirmative answer that it is updated every three months.

4.21 A The FHT has a semester evaluation of achieved results.( Y ) ( N )

Standard achieved, indicating the presence of an evaluative culture in the service. The team gathers every six months,

with or without the coordination, and conducts a comparative analysis of the population’s health profile, the coverage

and impact of the actions, using indicators previously established.

85


Commitment, Humanization and Responsibility

4.22 E

There is a differentiated assistance for the families in

situations of risk, high vulnerability and or social isolation. ( Y ) ( N )

The team knows and assists in a different way the families in situations of risk, high vulnerability and or social

isolation. Consider it an affirmative answer when concrete actions concerning these families may be presented, such

as: greater number of DV, priority in the scheduling of consultations, mobilization of the social net, among others.

Q Elementary

4.23 E

The information about the functioning of services is

available to the users in a clear and accessible way. ( Y ) ( N )

The standard refers to the team being sensitized and provides the population information that enables a greater and

better use of the available services. The standard considers that the information is transmitted to the users orally and

in writing, through placards placed at the FHU reception, for instance. Consider it an affirmative answer when all

members of the team act in the way indicated by the standard.

4.24 D

There is special care and assistance for the users in

illiteracy situation and social exclusion concerning the

service access and utilization. ( Y ) ( N )

The team members are sensitized and bear special careand clarification to the individuals with difficulty to obtain

information and/or comprehend the recommendations due to illiteracy and others situations of social exclusion. These

actions of commitment and humanization are fundamental to broaden the access and equity. Consider the answer

affirmative when all team members act in the way indicated in the standard.

Q Development

4.25 D

There is guiding criteria differentiating situations of

immediate care of the programmed ones. ( Y ) ( N )

The standard refers to the existence of a guiding document or protocol with orientations for the performance of

resolutive commitment (distinguishing situations of scheduling and instant attendance), available to the team profes-

sionals. These may have been created by the team itself, as well as by the coordination, MSH or other instance.

4.26 D

Resources for the registering of suggestions and

complaints are available to the users. ( Y ) ( N )

The standard refers to the availability and facilitation of the access to the urn, book, or other less formal mechanisms

of register (notes taken by the professionals when in direct contact with the population), of suggestions and com-

plaints, being that the users secrecy is guaranteed.

Q Consolidated

4.27 C

The FHT offers another schedule for the care of families

that can not attend during the customary functioning

period of the FHU or team work. ( Y ) ( N )

The standard refers to the FHT planning its 40 weekly hours enabling special schedules (after 6 p.m., or before 7 a.m.,

among others), to the assistance of family members who can not attend during the customary functioning period of the

FHU.

86


4.28 CDuring all the functioning period of the FHU people there

are listening to and caring for the users. ( Y ) ( N )

The standard refers to the reception of the users in integral period, listening to the demand in an appropriate space of

the FHU, by a team professional. From this qualified listening the actions and more appropriate services are deter-

mined, according the need of the users and the established clinical criteria.

4.29 CThe FHT evaluates and answers the suggestions and

complaints, enabling attendance to requests. ( Y ) ( N )

A higher standard comparing to the 4.26 referring to the weekly analysis of suggestions and complaints formally

received (written in urn, or book) or informally received, guiding the answers and actions to request attendance.

Q Better

4.30 B

The FHT develops initiatives to stimulate the development

of autonomy, self care and the co responsibility of the

users. ( Y ) ( N )

The standard refers to the FHT developing initiatives such as: operative groups, workshops or similar activities having

as a main axle the development of autonomy, self care and the co responsibility of the users. Consider the answer

affirmative when concrete experiences may be presented.

4.31 BThere is monitoring of the average waiting time for

services. ( Y ) ( N )

The FHT studies the attendance flow (demand), monitoring the average time between the moment of the user’s need

(scheduling) and the attendance of that service. From this analysis one may find solutions to reduce the waiting time

for the services. The standard considers only the services performed by its own team: consultations and procedures.

This monitoring can occur by sampling.

4.32 A

The FHT is sensitized to approach questions related to

stigmas, prejudice and racism, promoting a better

utilization of the health services.

( Y ) ( N )

The FHT is attentive and sensitized, noticing and approaching in the right way, at the FHU and at the community,

situations in which subjective processes such as: stigma, prejudice and racism exclude and make more difficult the

access of the users to the health services. Consider the answer affirmative when all team members act in the way

indicated by the standard.

Q Advanced

4.33 A

The services are available with no time restriction by life

cycles, pathologies or specific population groups.( Y ) ( N )

The standard refers to the offer of the services bases itself in a flexible and sensitive organization, which conciliates the

action planning to the population needs. In this situation, the planning of the actions by life cycles, pathologies or

specific population groups are references to assure the interests and needs of the users.

87


Health Promotion

Q Elementary

4.34 E

There are developed strategies to stimulate healthy

nutrition, respecting the local culture. ( Y ) ( N )

The standard refers to the team getting acquainted with the habits, culture and food used by the local population and

promoting the integration of its technical orientations to these aspects in the performance of health education activities

(operative groups, lectures and workshops) to stimulate healthy nutrition.

Q Development

4.35 D

Actions directed at the promotion of health environments

are organized, respecting the local culture. ( Y ) ( N )

Educational activities are developed such as lectures and operative groups, preferably with a participative methodology,

searching to broaden the knowledge about situations of sanitary, environmental and ecologic risk. These actions may occur in

partnership with NGOs or other institutions. To an affirmative answer consider the minimum frequency of every three months.

4.36 D

Strategies to face major local social problems are

developed together with the population. ( Y ) ( N )

The standard refers to the team meeting the community, in a systematic way, aiming to know the social problems and

formulate plans, projects and concrete strategies to fight them.

4.37 D

The FHT develops educational groups and groups of parent

acquaintanceship, approaching subjects of children’s health. ( Y ) ( N )

The standard refers to the FHT performing monthly, with the children’s parents in puericulture follow up, groups with

educational and acquaintanceship aspects, during which subjects related to children’s global care are approached:

nutrition, growth, stimuli to development, immunization, accident prevention, sleep, hygiene habits, limits and affec-

tion, among others.

4.38 D

The FHT organizes educational and acquaintanceship

activities with the hypertension people under care. ( Y ) ( N )

The standard refers to the organization, by the FHT members, of educational and acquaintanceship groups with the

hypertension people of the area, every two months, respecting the local culture and habits.

4.39 D

The FHT performs educational and acquaintanceship

actions with the diabetics under care. ( Y ) ( N )

The standard refers to the performance, by the FHT members, of educational and acquaintanceship groups with the

diabetics of the area, every two months, respecting the local culture and habits.

88


Q Consolidated

4.40 C

Systematic actions of health education at schools and child

care centers talking about children’s health are developed. ( Y ) ( N )

The standard refers to the development of actions and approaches to the subjects related to children’s global health,

performed at least twice a year by the FH teams. Consider the last twelve months to evaluate the standard.

4.41 C

Systematic actions of health education at schools approach

the health of adolescents and young people are developed. ( Y ) ( N )

The standard refers to the development of actions and approaches to the subjects related to the health of

adolescents and young people, performed at least twice a year by the FH teams. Consider the last twelve months to

evaluate the standard.

4.42 C

The FHT develops educational groups approaching the

subjects of sexuality and STD/AIDS prevention. ( Y ) ( N )

The standard refers to the FHT develops educational groups with the adult population of the area approaching themes

related to sexuality and DST/AIDS prevention, at least, every three months.

4.43 C

The FHT develops collective actions of socialization, health

promotion and improvement of the life quality for the elderly. ( Y ) ( N )

The standard refers to the FHT members developing monthly, collective actions of socialization, health promotion and

improvement of the life quality for the elderly trough acquaintanceship groups or other activities in the community,

such as: visits to cultural places, promenades, parties etc.

4.44 C

The FHT develops educational activities with the elderly

approaching contents related to their rights and the

Elderly Statute. ( Y ) ( N )

The standard refers to the FHT knows, values and develops educational activities with the elderly approaching sub-

jects related to their rights and the Elderly Statute.

4.45 C

The FHT develops educational and/or preventive actions

concerning domestic violence. ( Y ) ( N )

The team alone or in a partnership with a NGO, organizations and social movements performs campaigns and/or

meetings for clarification concerning conflict solving, non violence attitudes/behaviors and disarmament. The main

victims of domestic violence are children and women.

4.46 C

The FHT stimulates, develops and or follows up activities

within the field of corporal practices with the population. ( Y ) ( N )

The standard refers to the performance of some activities such as stretching, capoeira, walking, dance and oriental

practices (liang-cong, tai-chi-chuan, Chi-cong and others) by authorized professionals. Consider as affirmative, also, if

the actions are developed in partnership with social organizations.

4.47 C

The FHT develops strategies to the integration between the

popular knowledge and the technical scientific knowledge. ( Y ) ( N )

The standard refers to the development and register of concrete and systematic actions in the field of popular health

practices. There may be considered actions developed together with the Child Pastoral and/or other pastoral, social

movements, native magicians, among other social actors, in the perspective of knowledge exchange and integration.

89


Q Better

4.48 B

The team plans, executes and follows up the actions in its

acting area in partnership and/or informal articulation with

NGO, associations, councils, churches and social movements. ( Y ) ( N )

The FHT plans and executes projects and actions in partnership with public organisms, organizations and social

movements, contemplating the diagnosis of the health necessities/ community problems and its confrontation.

4.49 B

The FHT develops operative groups approaching contents

of sexuality and DST/AIDS prevention with the elderly. ( Y ) ( N )

The standard refers to the FHT being sensitized and able to approach contents of sexuality among the elderly and

DST/AIDS prevention, developing these through operative groups with the elderly.

4.50 B

The FHT develops actions of health education with a

problematic approach. ( Y ) ( N )

It is used the problematic approach, according the Net of Popular Education in Health. See site:

www.redepopsaude.com.br

4.51 B

The FHT develops actions for the integration of the

mental patients in regular collective activities. ( Y ) ( N )

The standard refers to the insertion of the mental patients in FHT operative groups, workshops, activities of commu-

nity acquaintanceship, cultural, leisure etc. To an affirmative answer consider the participation of these users in

monthly activities.

Q Advanced

4.52 A

The FHT performs educational and/or preventive actions

concerning traffic accidents. ( Y ) ( N )

The team alone or in partnership with NGO, organizations or social movements performs campaigns and or/ elucida-

tion meetings concerning traffic care, including orientations about trampling. Educational actions may occur at schools,

public squares etc. the answer must be affirmative when the actions occur at least every six months.

4.53 A

There are initiatives in progress, performed together with

the population, with emphasis in the community

development. ( Y ) ( N )

The standard refers to the existence of initiatives emphasizing community development, in which the team partici-

pates or performs together with the population and or social movements: community vegetable garden, activities to

gain money and literacy, among others. To an affirmative answer, consider experiences working continuously in the

last 24 months.

4.54 A

The assistance of alcohol and other drugs users in the

perspective of damage reduction and strengthening of the

community and social network is performed. ( Y ) ( N )

The standard refers to the FHT aware of the perspectives of damage reduction and strengthening of the community

and social network, and assisting the users of alcohol and drugs who are under treatment.

90


Community Participation and Social Control

Q Development

4.55 D

The FHT debates regularly with the community themes of

citizenship, right to health and SUS functioning. ( Y ) ( N )

The standard refers to the FHT develops, at least once every three months, lectures, operative groups or other

participative activities in which themes like citizenship, right to health and SUS functioning are the main focus. These

actions may be developed together with other public organisms or social organizations.

4.56 C

The FHT meets with the community every three months

to debate the local health problems, the assistance given

and the results obtained. ( Y ) ( N )

The standard refers to meetings with the community and or its representatives, once every three months, to debate

and evaluate health problems, the assistance given and the results of the developed actions, registering in the appro-

priate medium, the relevant aspects and guidance.

Q Consolidated

Q Better

4.57 BThe FHT takes part in meetings with health councils.

( Y ) ( N )

The standard considers the participation of one or more integrants of the team in meetings with health councils (Local

Health Council, District and or Municipal Health Council). Consider as affirmative answer if the frequency is higher or

equals to 75% of the reunions, being considered valid the participation in turns among the team integrants or the

formally elected members, with right to vote.

Q Advanced

4.58 A

There is participation of representatives of the social

movements and users in the process of FHT work planning. ( Y ) ( N )

The standard refers to community representatives and social movements participating in an effective way in the

process of action planning to be achieved by the team, searching to broaden the comprehension towards the health

needs of the population and improve interchange. To an affirmative answer consider the presence of the community

representatives in monthly planning meetings in the last twelve months.

Health Surveillance I: General Actions

Q Elementary

4.59 E

The FHT develops monitoring actions of the nourishment

and nutrition situation of the population. ( Y ) ( N )

It refers to the activities of identification, registering, assistance and follow up of children and pregnant women,

registering data at SISVAN, according the Technical Norm of Nourishment and Nutrition Surveillance (http://

portalweb01.saude.gov.br/alimentacao/documentos/orientacoes_basicas>_sisvan.pdf).

91


4.60 E

The FHT professionals perform an active search to the

detection of new cases of Systemic Arterial Hypertension

in the population. ( Y ) ( N )

The standard refers to the regular performance of activities in the community concerning the detection of arterial

hypertension, including the measure of arterial hypertension (www.saude.gov.br/hipertensao-diabetes).

4.61 E

The HCA develop educational actions in the community

aiming the eradication of domiciliary focus of Aedes

aegypti. ( Y ) ( N )

The standard refers to the development of systematic actions by the FHT together with the community to the eradica-

tion of the domiciliary focus of Aedes aegypti orienting (and sometimes organizing quilting bees) towards tires,

bottles, plant vases, water tanks etc. Consider to an affirmative answer, at least, one monthly activity in the period

from September to March.

4.62 E

The FHT performs a compulsory notification of the

diseases or sends a weekly negative report. ( Y ) ( N )

The FHT knows and performs proceedings related to the compulsory notification of diseases, contributing to the

nourishment of the Reportable Health Events Information System – SINAN.

4.63 D

The FHT performs actions in order to detect new cases of

tuberculosis. ( Y ) ( N )

Actions to detect tuberculosis are performed, including active searches among the communicants and other suspicious

cases (chronic cough).

Q Development

4.64 D

The FHT develops actions having as a focus sanitary and

environmental surveillance. ( Y ) ( N )

The standard refers to the team developing, with the population, in a regular and permanent way, actions focusing on

the environment, of an educative or interventional character, approaching questions like: manipulation and conserva-

tion of the food etc.

4.65 C

The FHT performs an active search to detect new cases of

diabetes Mellitus in the population. ( Y ) ( N )

The standard refers to the regular performance of activities in the community to detect new cases of Diabetes Mellitus,

including the realization of capillary glycemia (www.saude.gov.br/hipertensao-diabetes).

Q Consolidated

4.66 C The FHT performs actions to detect new cases of Hanseniasis. ( Y ) ( N )

Actions to the detection of Hanseniasis are characterized by the active search among communicators and other

suspicious cases.

92


4.67 B

The FHT develops actions to identify risky situations

among the elderly population. ( Y ) ( N )

The standard refers to the FHT being sensitized and aware of the risky situations to which the elderly population is

exposed: abandonment, depression, nutritional lacks, domestic accidents, intoxications through self medication, among

others. In this way, domiciliary visits and meetings with the community may enable actions of identification of these

situations. Consider the answer affirmative when all team members act in the way indicated by the pattern.

Q Better

4.68 B

The FHT is sensitized to identify and act in situations of

sexual and domestic violence. ( Y ) ( N )

The identification of cases through a direct communication channel through the victims/neighbors or during domicili-

ary visits constitutes a fundamental step to counseling, prevention and combating this kind of violence. Actions like

notification and activation of the available resources in other public organisms are mandatory. Consider the answer

affirmative when all team members act in the way indicated by the pattern.

4.69 A

The FHT assists the population’s health according its ethnics

origins concerning the risks and vulnerability associated. ( Y ) ( N )

The standard refers to the team knows and be sensitized concerning health problems and risks that occur in a more

intense manner in certain ethnic groups. Prejudice is of a positive aspect aiming a greater care to these segments of the

population. In Brazil, there is the development of guidelines and actions concerning the health of afro-brazilian popu-

lation. Consider the answer affirmative when all team members act in the way indicated by the pattern.

Q Advanced

4.70 A

The FHT develops actions of surveillance in the territory, having

as its focus the reduction of risks to the worker’s health. ( Y ) ( N )

The FHT is sensitized to the occurrence of risks, diseases and health problems related to occupational health (http://

www.opas.org.br/saudedotrabalhador). Consider the answer affirmative when all team members act in the way indi-

cated by the standard.

93


Notes

94




Tool nº 5

Health Care

Children’s Health

Q Elementary

5.1 E There is an updated register of children up to five years old.( Y ) ( N )

The standard refers to the FHT having, registered and documented on paper, its child population up to five years old,

discriminated by age (year by year) and gender, updated monthly. From the knowledge of this population it is possible

to develop many other actions indicated in the higher quality levels. Answer in an affirmative way when the updating

is permanent, including the updating of the information system.

5.2 E

The child’s card or note book is evaluated and filled out

at every situation of search for care. ( Y ) ( N )

The standard refers to every team member knows the child’s card or note book, and be sensitized to the importance of

this tool in the follow up of the infantile population requiring its presentation by the parents or responsible ones and

evaluating it (and filling it out whenever it is necessary), in all situations of search for care.

5.3 EAll FHT members are able to recognize and orient actions

in cases of child dehydration. ( Y ) ( N )

The standard refers to all FHT members being able to recognize the main symptoms of child dehydration and being

able to orient the preparation and giving of the oral re hydration solution or the oral re hydration salts distributed or

bought in drugstores.

5.4 EThe FHT develops systematic, collective and individual

actions of incentive to breastfeed in prenatal and puerperium. ( Y ) ( N )

The standard refers to the FHT stimulating and orienting breastfeeding, in groups of pregnant women or to each one

individually when it is necessary, with programmed regularity. The ideal is that these actions happen every month,

during prenatal appointments.

5.5 E

80% or more of the children of the area up to one year

old are under growth and development assistance. ( Y ) ( N )

The standard refers to the coverage of the periculture actions, specifically the assistance component of G&D, in the

population of children up to one year old within the FHT acting area. It is aimed the realization of, at least, seven

consultations in the first year: 15 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months. Consider for

an affirmative answer the coverage with seven consultations, no matter the moment they happened.

95


5.6 E90% or more of the children of the area up to one year

old have their vaccination updated. ( Y ) ( N )

The standard refers to the coverage of the puericulture actions, specifically the immunization component, in the

population of children up to one year old of the FHT acting area.

5.7 D

The FHT performs the approach of the danger/risk signs

in the children brought to the FHU assistance,

establishing priority in the assistance and follow up. ( Y ) ( N )

The standard refers to the flow chart “Approach of children’s risk in the health unit” presented at page 73 of the

Agenda of Appointments for Children’s Complete Health and Reduction of Infantile Mortality, published in 2004. If

the FHT uses any other flow chart or protocol, it is mandatory that the situations of immediate assistance by the doctor

are established (http://dtr2001.saude.gov.br/bvs/publicacoes/agenda_compro_crianca.pdf).

5.8 D80% or more of the children up to 5 years old, in

situation of risk, are being assisted by the FHT. ( Y ) ( N )

The standard refers to the FHT having a register of the population up to five years old; identify the ones who are in

situations of risk (Agenda of Appointments for Children’s Comprehensive Health and Reduction of Infantile Mortality,

MS, 2004 – http://saude.gov.br/bvs/publicacoes/agenda_compro_crianca.pdf) and follow them up every month through

medical appointments and nursing, DV, guidance and regular operative groups. Period for evaluation: last 12 months.

Calculate the percentage for each month as in the standard 5.5, considering as a denominator the total child population

in situation of risk. Calculate the simple average among the 12 months evaluated.

5.9 D80% or more of the NB got two consultations within

their first month of life. ( Y ) ( N )

The standard refers to the actions defined by the First Week of comprehensive Health (Agenda of Appointments for

Children’s Comprehensive Health and Reduction of Infantile Mortality, MS, 2004 – http://saude.gov.br/bvs/publica-

coes/agenda_compro_crianca.pdf). Consider the last 12 months for the evaluation of the standard indicator.

Q Consolidated

5.10 C80% or more of the children between one and five years

old of the area are being assisted by the FHT. ( Y ) ( N )

The standard refers to the FHT having a register of the population between one and five years old and assisting them

through medical consultations and nursing, DV, guidance and regular operative groups, concerning the growth, develop-

ment and immunization. Consider the last 12 months to the evaluation of the standard indicator. Consider at least two

evaluations per year to children between 12 and 24 months. After this age, consider one consultation per year.

Q Development

5.11 CThe team assists the buccal health of the children up to

five years. ( Y ) ( N )

The standard refers to the FHT having a register of the population between one and five years old and assisting them,

concerning the buccal health, at least, when it comes to teeth development, maintenance of the buccal health and the

continuance of oral habits harmful to the normal establishment of the bite pattern (suction of the finger and pacifier, for

instance). It is included here the incentive to breastfeeding and parents guidance.

5.12 CThe FHT develops actions of assistance of children with

asthma according the clinic protocol established. ( Y ) ( N )

The standard refers to the conjunct of actions developed in an integrated way by the team professionals, considering

their various attributions, to the detection, diagnosis and treatment of asthma in the infantile population, according the

clinic protocol, aiming to reduce the hospitalizations and mortality due to respiratory diseases.

96


5.13 CThe prevalence of exclusive breastfeeding up to 30 days

is 90% or more. ( Y ) ( N )

The standard refers to the monitoring of the prevalence of exclusive breastfeeding up to 30 days of life. Period of

evaluation: 12 months.

Q Better

5.14 B

There was a reduction of the absolute number of

hospitalizations by acute respiratory infections in the

population up to five years old, or absence of cases. ( Y ) ( N )

Consider the period of 24 months to the evaluation of this standard indicator. The data are contemplated at the SIAB,

being also one of the indicators in the Indicators of Primary Care Pact. It aims to evaluate if the actions directed to the

infantile population are influencing the health indicators. The standard demands only that the hospitalizations in an

absolute number are in constant downfall in this age group by the FHT members (see SIAB).

5.15 BThe malnutrition among children under 2 years old is in

downfall or does not exist. ( Y ) ( N )

The standard refers to the monitoring of malnutrition in the population up to two years old, observing if within the

period comprehended by the last 24 months the curve is descendant or there were no cases. It implicates in the follow

up of the weight of the population in this age group by the FHT members (see SIAB).

5.16 BThere was a reduction of the absolute number or

absence of cases of NB under weight at birth. ( Y ) ( N )

The standard refers to the monitoring of the weight of the NB in the population, observing whether, in the last 24

months, there has been a reduction or absence of the absolute number of NB who were born underweight. This

standard reflects, mainly, the cares assisted during prenatal.

5.17 B All neonatal deaths are investigated.( Y ) ( N )

The standard refers to the FHT participation in the investigation of all children’s deaths between 0 and 27 days,

weighting more than 1.500 g. The guidance to the investigations is described at the Manual of the committees of fetal

and infantile death prevention of the HD (2004) - http://dtr2001.saude.gov.br/bvs/publicacoes/

MS_manual_finalizadoOBITOS.pdf. Answer in an affirmative way to the standard in the case of absence of known

deaths in the last 12 months.

5.18 BThe prevalence of exclusive breastfeeding at 6 months

old is of 60% or more. ( Y ) ( N )

The standard refers to the monitoring of the prevalence of exclusive breastfeeding up to six months old.

5.19 BThe sealing of the four first molars occurs in cases with

clinical advisement. ( Y ) ( N )

The standard refers to the action performed by the BHT in the infantile population between 5 and 7 years, according

a clinic advisement.

97


Q Advanced

5.20 A80% or more of the children in the area between 5 and

10 years old are being assisted by the FHT. ( Y ) ( N )

The standard refers to the FHT having a register of the population between 5 and 10 years old and assisting them

through medical and nursing consultations, DV, guidance and regular operative groups, concerning G&D and immu-

nization. Consider at least one evaluation per year for the children between 5 and 10 years old.

5.21 AAll infantile deaths occurred in the last 12 months were

investigated. ( Y ) ( N )

The standard refers to the FHT participation in the investigation of all deaths of children up to 1 year old, born

weighting 1.500 g or more (neonatal and postnatal) and also the fetal deaths (stillbirths) weighting 2.500 g or more

at birth. The guidance to the investigations is described at the Manual of the committees of fetal and infantile death

prevention of the MH (2004) - http://dtr2001.saude.gov.br/bvs/publicacoes/MS_manual_finalizadoOBITOS.pdf. Answer

in an affirmative way to the standard in the case of absence of known deaths in the last 12 months.

5.22 AThe prevalence of breastfeeding at 12 months is of 70%

or more. ( Y ) ( N )

The standard refers to the monitoring of the prevalence of the non exclusive breastfeeding in the population up to 12

months.

5.23 A80% or more of the NB got a consultation in their first

week of life. ( Y ) ( N )

The standard refers to medical or nursing consultation. See actions defined in the First Week of Comprehensive Health

(Agenda of Appointments for Children’s Comprehensive Health and Reduction of Infantile Mortality, MS, 2004 –

http://saude.gov.br/bvs/publicacoes/agenda_compro_crianca.pdf). Consider the last 12 months for the evaluation of

the standard indicator.

5.24 AThere was a reduction of the ceo-d indicator in the

population from 5 to 6 years old in the last 24 months. ( Y ) ( N )

This indicator demonstrates resolubility in the buccal health care, especially in its component of dental cavity preven-

tion. Consider, for the evaluation of the standard indicator, the last 24 months.


Q Development

5.25 D The FHT has an updated register of the adolescents of the area.( Y ) ( N )

The standard refers to the FHT having, registered and documented in paper, the number of teenagers (SIAB: 10 to 14

and 15 to 19 years old), distinguished by gender, of the FHT enrolled area, updated every six months. From the

knowledge of this population it is possible the development of many other actions indicated in the higher quality

levels. Answer affirmatively when the updating is permanent, including the updating of the information system.

98


Q Consolidated

5.26 C50%or more of the registered adolescents have the

vaccination updated. ( Y ) ( N )

The standard refers to the FHT having a register of the population from 10 to 14 and 15 to 19 and following them up

through consultations, DV and regular operative groups, concerning immunization. Consider the vaccines recom-

mended by the MH or SSH for the age group. Consider the last 12 months for the evaluation of the standard indicator.

Q Better

5.27 B50% or more of the adolescents assisted with a

consultation for growth and development evaluation. ( Y ) ( N )

The standard refers to the FHT having a register of the population from 10 to 14 and 15 to 19 and following them up

through medical and nursing consultations, DV and regular operative groups, concerning G&D. Consider an annual

evaluation. Consider the last 12 months for the evaluation of the standard indicator.

5.28 BThe FHT develops educational activities to the

adolescents about sexual and reproductive health. ( Y ) ( N )

The standard points to the development of actions and approaches of specific contents of sexual and reproductive

health of the adolescents, offering contraceptive methods (condoms, oral and injected contraceptives, according the

advisement), and performed at least twice a year. Consider the last 12 months for the evaluation of the standard.

Q Advanced

5.29 AThere was a reduction of the non planned pregnancies

among the adolescents assisted by the FHT. ( Y ) ( N )

The standard refers to the monitoring of the incidence of non planned pregnancies among the population between 15

and 19 years old, assisted by the team. Consider the last 24 months. Consider to an affirmative answer the reduction

of the absolute number of cases within the period.

5.30 AThere was a reduction of the CPO-D indicator in the 12

year old population over the last 24 months. ( Y ) ( N )

This indicator demonstrates resolubility in the buccal health care, especially in its component of dental cavity preven-

tion. Consider, to the evaluation of the standard indicator, the last 24 months.

Adult Women and Men’s Health

Q Elementary

5.31 EThe FHT has an updated register of the adults of the

area by gender and age group. ( Y ) ( N )

The standard refers to the FHT having, registered and documented in paper, the number of adults (20 to 59 years old)

of the FHT enrolled area, distinguished by age groups (see SIAB) and gender. From the knowledge of this population

it is possible the development of many other actions indicated in the higher quality levels. Answer affirmatively when

the updating is permanent, including the updating of the information system.

99


5.32 EThere is a wide access to the low risk prenatal by the

population. ( Y ) ( N )

The low risk prenatal, with offer of consultations, laboratory routine exams and tetanus immunization, performed in an

alternate and complementary way (medical and nursing consultations), is considered one of the most elementary

actions of the Primary Care, impacting in a very positive way the maternal-infantile indicators. It is recommended the

realization of 4 to 6 consultations. The minimum evaluation has: nutritional evaluation, PA measure, uterine height,

auscultation of the focus (after the 4° month).

5.33 E

There are performed educational activities during

prenatal approaching themes related to pregnancy,

deliverance and puerperium.( Y ) ( N )

The standard refers to the monthly performance of educational activities, linked to consultations, with the pregnancy

population in prenatal care, in a regular and programmed way, approaching themes related to pregnancy, deliverance,

puerperium and cares with the NB.

5.34 EThe FHT has an updated register of the hypertenses of

the area. ( Y ) ( N )

The standard refers to the FHT having, registered and documented in paper, the number of hypertenses referred to and

confirmed, distinguished by age groups (see SIAB) and gender, updated every month. From the knowledge of this

population it is possible the development of many other actions indicated in the higher quality levels.

5.35 E The FHT has an updated register of the diabetics of the area.( Y ) ( N )

The standard refers to the FHT having, registered and documented in paper, the number of diabetics referred to and

confirmed, distinguished by age groups (see SIAB) and gender, updated every month. From the knowledge of this

population it is possible to develop of many other actions indicated in the higher quality levels.

Q Development

5.36 DThe FHT monitors the frequency of the hypertenses to

the programmed activities. ( Y ) ( N )

The standard refers to the FHT monitoring the frequency of the hypertenses to the programmed activities, trying to

assure the adhesion to collective and individual activities and engaging in an active search of the absent ones.

5.37 DThe FHT monitors the frequency of the diabetics to the

programmed activities ( Y ) ( N )

The standard refers to the FHT monitoring the frequency of the diabetics to the programmed activities, trying to assure

the adhesion to collective and individual activities and engaging in an active search of the absent ones

5.38 DThe hypertenses under assistance have an individual

consultation, at least, once in every three months. ( Y ) ( N )

The standard refers to the FHT having recommended and assured, at least, one individual consultation every three

months for the hypertenses under assistance.

5.39 D80% of the diabetics under assistance have an individual

consultation, at least, once in every three months. ( Y ) ( N )

The standard refers to the FHT having recommended and assured, at least, one individual consultation every three

months for the diabetics under assistance.

100


5.40 D

80% or more of the pregnant women with an early

prenatal beginning. ( Y ) ( N )

The standard indicator refers to the FHT monitors and develops actions of early captivation of pregnant women (up to

the first three months of pregnancy, that is, 90 days) to the beginning of prenatal care. The survey may occur trough

the B-GES file card of the SIAB. Calculate the percentage, considering to the evaluation the last 12 months and verify

if it meets the parameters established for the standard.

5.41 D80% or more of the low risk pregnant women with 7 or

more prenatal consultations attended. ( Y ) ( N )

The standard indicator refers to the monitoring of the percentage of pregnant women who had at least seven consul-

tations or more of low risk prenatal during pregnancy, considering the last 12 months. Verify if this percentage

considers the parameters established by the quality standard.

5.42 D The FHT develops monthly actions of family planning.( Y ) ( N )

The standard refers to the performance of educational monthly actions of family planning, individual or in groups, with

guidance concerning the use and offer of basic contraceptive methods: condoms, oral and injected contraceptives,

according advisement.

5.43 D

The FHT develops systematic actions, individual or in

groups, of cervix uteri cancer prevention and breast

cancer control. ( Y ) ( N )

The standard refers to the and performance of collective and individual actions of cervix uteri and breast cancer

prevention, at least every two months, concerning actions of guidance and self examination to the sensitization and

achievement of cervix uteri cytology aiming to reach coverage rates within the feminine population over 90%.

5.44 DThe FHT performs an active search of the positive cases

of cervix uteri cytology. ( Y ) ( N )

The standard refers to the monitoring of all citologies gathered and sent to analysis, performing an active search of the

users with a positive exam, guiding or performing the indicated procedure.

5.45 DThe professional perform the treatment of the prevalent

STDs approaching the partner(s). ( Y ) ( N )

The standard refers to the partner(s)’ approach being standardized and accomplished in all situations of therapeutic

approach of the STDs by the FHT professionals with a college degree.

5.46 D80% of women who have recently given birth with a puerperium

appointment performed up to 42 days after deliverance. ( Y ) ( N )

The standard indicator refers to the continuity of the care actions during the puerperium, considering to the evaluation

the last 12 months. The answer must be affirmative when, at least, one consultation (medical and/or nursing) is

performed up to 42 days after deliverance.

5.47 DIt is performed syphilis diagnosis and treatment during

pregnancy. ( Y ) ( N )

The standard refers to the professionals with a college degree of the FHT being sensitized to require routinely exams

to the syphilis detection during prenatal, performing the recommended treatment when it is needed.

101


5.48 D The FHT has an updated register of the mental patients.( Y ) ( N )

The standard refers to the team having, documented in paper, the register of the mental patients, distinguishing kind

of diseases, age, gender, address, family situation, autonomy degree and whether it is being assisted by the reference.

Q Consolidated

5.49 CThe care to the hypertense population occurs from risk

classification. ( Y ) ( N )

The planning of the hypertense care is performed using the classification according the hypertension type, adhesion

and answer to the treatment, presence of associated risk factors, instruction and autonomy degree, among other

factors. The frequency of medical and nursing consultations is proposed and achieved from this evaluation, according

the consensus for the theme (www.saude.gov.br/hipertensao-diabetes).

5.50 CThe care to the diabetic population occurs from risk

classification ( Y ) ( N )

The planning of the hypertense care is performed using the classification according the diabetic type, adhesion and

answer to the treatment, presence of associated risk factors, instruction and autonomy degree, among other factors.

The frequency of medical and nursing consultations is proposed and achieved from this evaluation, according the

consensus for the theme (www.saude.gov.br/hipertensao-diabetes).

5.51 CThe BMI of all hypertenses assisted by the FHT happens

every three months. ( Y ) ( N )

The standard refers to the trimestrial measure of the BMI of all hypertenses assisted by the FHT, with register in an

individual file card, allowing monitoring of the past situations and evolution of the marking.

5.52 CThe BMI of all diabetics assisted by the FHT happens

every three months ( Y ) ( N )

The standard refers to the trimestrial measure of the BMI of all hypertenses assisted by the FHT, registering in an

individual file card.

5.53 CThe exam of the feet of the assisted diabetics is

performed at every consultation. ( Y ) ( N )

The standard refers to the FHT having as a recommended routine and performing in a systematic way the exam of the

diabetics feet in every consultation.

5.54 CThe FHT analyses every six months the population of

assisted hypertenses considering the estimated prevalence. ( Y ) ( N )

The standard refers to the FHT comparing, every six months, whether the population of diagnosed hypertenses under

assistance is compatible with the expected number according the calculation of the hypertense estimated prevalence

for the territory. The prevalence of the systemic arterial hypertension for Brazil is around 15 to 20%.

5.55 CThe FHT analyses every six months the population of

assisted diabetics considering the estimated prevalence. ( Y ) ( N )

The standard refers to the FHT compares, every six months, whether the population of diagnosed diabetics under

assistance is compatible with the expected number according the calculation of the diabetic estimated prevalence for

the territory. The prevalence of Diabetes Mellitus for Brazil is around 6 to 11%.

102


5.56 C80% of the pregnant women assisted in the prenatal are

under FH assistance. ( Y ) ( N )

Consider for the evaluation of the standard indicator, the percentage of low risk pregnant women assisted by the team

who received at least one dental evaluation by pregnancy trimester, over the last 12 months. The Dental Care for the

pregnant women comprehends the achievement of a diagnosis evaluation, caterings and surgeries when indicated,

considering the pregnancy period, besides the education and prevention actions.

5.57 CThe clinic breast exam is a routine established in the

service. ( Y ) ( N )

The standard refers to the clinic breast exams being performed, at least, once a year, systematically in all consultations

of women from 40 to 69 years old as a service routine. Do not consider the refusals by the users, due cultural factors.

5.58 CThe FHT develops sensitization actions together with the

masculine population to the early detection of prostate cancer. ( Y ) ( N )

The standard refers to the FHT orients and sensitizes the population of men from 40 to 65 years old concerning the

available measures to the early detection of prostate cancer.

5.59 CThe FHT keeps follow ups of the mental patients assisted

by the reference. ( Y ) ( N )

The standard refers to the FHT being acquainted with the mental patients of its territory who are being assisted by

the reference, keeping a follow up through DV or consultations at the FHU, in a way integrated with the Mental

Health team.

5.60 CThe BHT develops preventive actions turned to the users

with special needs. ( Y ) ( N )

The standard refers to the BHT developing actions aiming the prevention, directed to the people with special needs,

such as: the sensitization and capacitation of the people in charge for the oral hygiene, among others.

Q Better

5.61 BThe FHT keeps a follow up of the treatment by reference

of the users of alcohol and other drugs. ( Y ) ( N )

The standard refers to the FHT being acquainted with the drug users of its territory who are being assisted by the

reference, keeping a follow up through DV or consultations at the FHU, in a way integrated with the Mental Health.

5.62 B Male adults are assisted by the FHT.( Y ) ( N )

The standard refers to the FHT having a register of the population between 20 and 59 years old and following them

up through medical and nursing consultations, concerning the general health conditions and health problems preven-

tion. To an affirmative answer, consider 50% of the male population of this age group.

5.63 B

The adult men and women population is under systematic

assistance by the BH. ( Y ) ( N )

The standard refers to the BHT developing actions of follow up of the population within this life cycle. Consider to an

accurate answer 60% of the population considered over the last 12 months.

103


5.64 BThere was a reduction of the absolute number of

hospitalizations by Cerebral Vascular Accident. ( Y ) ( N )

The standard refers to the reduction of the absolute number of hospitalizations by vascular cerebral accident over the

last 24 months, to the enrolled population between 40 and 69 years old, accompanied. It is one of the themes

approached by the Indicators of Primary Care Pact.


hospitalizations by Acute Myocardial Infarct. ( Y ) ( N )

The standard refers to the reduction of the absolute number of hospitalizations by Acute Myocardial Infarct over the

last 24 months, to the enrolled population, accompanied.


hospitalizations by complications due to Diabetes Mellitus. ( Y ) ( N )

The standard refers to the reduction of the absolute number of hospitalizations by ketoacidosis and diabetic coma over

the last 24 months, to the enrolled population, accompanied. It is one of the indicators of the Indicators of Primary

Care Pact.

5.67 BThere was a reduction or absence of psychiatric

hospitalizations of mental patients. ( Y ) ( N )

The standard refers to the reduction of the absolute number of psychiatric hospitalizations of the mental patients of the

territory over the last 24 months.

Q Advanced

5.68 A

The FHT develops activities of reintegration and

community rehabilitation together with the mental

Health teams of reference. ( Y ) ( N )

The standard refers to the FHT developing actively projects and actions of reintegration and community rehabilitation

together or with the advisement of the mental Health team of reference.

Elderly’s Health

5.69 DThe FHT has an updated register of the elderly people

within the area. ( Y ) ( N )

The standard refers to the FHT having, registered and documented on paper, the number of elderly (SIAB: over 60

years old), discriminated by gender, enrolled area to the FHT, updated every month. The ideal is that there are

references to the clinic situations: diseases, hospitalizations etc. From the knowledge of this population it is possible

to development of many other actions indicated in the higher quality levels. Answer affirmatively when the updating

is permanent, including the updating of the information system.

Q Development

Q Consolidated

5.70 C80% or more of the elderly in the area have the

vaccination updated. ( Y ) ( N )

The standard refers to the FHT monitoring vaccination coverage of the elderly. Compare the coverage reached with the

value established for the quality standard.

104


Q Better

5.71 BThe exam of the oral cavity of the elderly is a routine

established in the service. ( Y ) ( N )

The standard refers to the FHT and BHT having as a recommended routine and performing in a systematic way the

exam of the oral cavity of the elderly assisted, aiming the identification of cancerous lesion, in all consultations

performed by professionals with a college degree.

5.72 B The elderly are under systematic assistance by the BH.( Y ) ( N )

The standard refers to the BHT developing actions of assistance of the elderly population and monitoring the coverage

of the consultations within this age group. Consider, to an affirmative answer, coverage of 60% of the population

considered, over the last 12 months.

5.73 BThe exam of the body surface of the elderly is a routine

established in the service. ( Y ) ( N )

The standard refers to the FHT and BHT having as a recommended routine and performing in a systematic way the

exam of the body surface of the elderly assisted, aiming the identification of cancerous lesion, in all medical and

nursing consultations.

Q Advanced

5.74 AThe FHT develops interventions concerning the family of

the elderly, capacitating domiciliary care takers. ( Y ) ( N )

The standard refers to the FHT performing interventions together with the family of the elderly in the indicated cases,

identifying and capacitating people to develop the appropriate family cares.

5.75 AThere are developed appropriated interventions together with

the elderly population to the early detection of dementia. ( Y ) ( N )

The standard refers to the FHT members being sensitized to recognize the main dementia characteristics incident over

the elderly population (Parkinson, Alzheimer, micro vascular diseases etc).

Health Surveillance II: Transmissible Disease

5.76 DThe FHT monitors the regularity of the treatment of the

tuberculosis patients. ( Y ) ( N )

The standard refers to the FHT monitoring the regularity of the users under tuberculosis treatment to the sched-

uled consultations, performing an active search of the absent ones and trying to guarantee the continuity of the

initiated treatment.

Q Development

5.77 DThe FHT monitors the regularity of the treatment of the

leprosy patients. ( Y ) ( N )

The standard refers to the FHT monitors the regularity of the users under leprosy treatment to the scheduled

consultations, performing an active search of the absent ones and trying to guarantee the continuity of the

initiated treatment.

105


5.78 DThe differential diagnosis approach to dengue is

performed every time it is advised. ( Y ) ( N )

The standard refers to the FHT doctor knows the dengue epidemiologic aspects and patho-physiological manifesta-

tions, performs a physical exam – especially testing of capillary resistance (lace testing), requires the proper laboratory

examinations and interprets them, making the disease diagnostic.

Q Consolidated

5.79 CThe diagnosis, prescription and follow up of the

supervised treatment occur in the tuberculosis cases. ( Y ) ( N )

The standard refers to the FHT being able to perform all the described actions: diagnosis, treatment, prescription and

follow up of the tuberculosis supervised treatment.

5.80 CThe diagnosis, prescription and follow up of the

supervised treatment occur in the leprosy cases. ( Y ) ( N )

The standard refers to the FHT being able to perform all the described actions: diagnosis, treatment, prescription and

follow up of the leprosy supervised treatment

5.81 CThe anti-HIV exam is offered with counseling to all

pregnant women assisted. ( Y ) ( N )

The standard refers to the offering of the anti–HIV exam with counseling being standardized to all pregnant women

under prenatal assistance. Consider the last 12 months to the standard analysis.

5.82 CThe exam for the detection of hepatitis B and C is offered

with counseling to the women and men assisted. ( Y ) ( N )

The standard refers to the offering of exams to the detection of hepatitis B and C, with counseling, to all adults

assisted, being an established routine in the FHT.

5.83 CThe dengue cases are leaded to hospitalization whenever

necessary. ( Y ) ( N )

The standard refers to the follow up (of the evolution) of the dengue infection, with the recognition of the dangerous

signs and of the situations that indicate hospitalization, whenever necessary.

5.84 CThere are performed immediate interventions in cases of

outbreaks by infectious contagious disease. ( Y ) ( N )

The standard refers to the FHT being able to and developing actions of epidemiologic surveillance, intervening on the

contacts and communicators to the diagnosis, treatment and/or actions of blocking and prevention, in the cases of

contagious diseases outbreaks.

Q Better

5.85 B90% of the tuberculosis patients diagnosed and treated

are cured. ( Y ) ( N )

The standard is a result standard and evaluates the impact of the actions over the population’s health. Verify the

percentage of tuberculosis patients diagnosed, who went under complete treatment (with no interruptions), that were

cured. Consider the last 24 months to evaluation.

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5.86 B90% of the patients diagnosed with leprosy and treated

are cured. ( Y ) ( N )

The standard is a result standard and evaluates the impact of the actions over the population’s health. Verify the

percentage of leprosy patients diagnosed, who went under complete treatment, which were cured. Consider the last

24 months to the evaluation

5.87 B The absence of neonatal tetanus in the area.( Y ) ( N )

Consider to an affirmative answer the evaluation of the last 24 months. The standard refers to a final result on the

health of the population covered by the FHT to which contributed all the actions previously performed of prevention

and follow up, especially prenatal.

5.88 B Absence of congenital syphilis in the area.( Y ) ( N )

Consider to an affirmative answer the evaluation of the last 24 months. The standard refers to a final result on the

health of the population covered by the FHT to which contributed all the actions previously performed of prevention

and treatment, especially prenatal.

Health Surveillance III: Regional Health Problems

5.89 DThe differential diagnosis approach to malaria is

performed every time it is advised. ( Y ) ( N )

The standard refers to the FHT doctor knows the malaria epidemiologic aspects and patho-physiological manifesta-

tions (high fever in cycles, sweating, chills, myalgia and headache) being able to collect the anamnesis and perform the

physical exam, require the proper laboratory examinations and interpret them, making the disease diagnostic.

Q Development

5.90 CThe malaria cases are leaded to hospitalization whenever

necessary. ( Y ) ( N )

The standard refers to the FHT doctor prescribes the indicated medicine and follows up malaria evolution, being able

to recognize the dangerous signs, complications and the situations that indicate the hospitalization.

Q Consolidated

Suggestions of themes to Loco-regional Standards

Examples:

Violence/external Causes

Indigenous Health

Remaining Community of Quilombos

Initiatives related to natural Medicine and Complementary Practices

(Homeopathy, Chinese Traditional Medicine, Anthroposophic medicine and

Phytotherapy)

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Notes

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Notes

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Notes

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Visit the project website:

www.saude.gov.br/amq

Questions, suggestions and contributions:

[email protected]

Avaliação para Melhoria da Qualidade

da Estratégia Saúde da Família

Telephones: + 55 61 3315 2391

+ 55 61 3315 3434

Documents

EVALUATION FOR QUALITY IMPROVEMENT OF THE FAMILY …189.28.128.100/dab/docs/publicacoes/geral/doc_tec_amq_ingles.pdf · IV. Guidelines for the Evaluation for Quality Improvement of